COLUMBIA  LIBRAHita  "rr^''^ 
HEALTH  SCIENCES  STANDARD 


HX00035971 


J 


r 
V 


6^ 


•  ■^f^afryjTWT^  »»'.*i-i 


THE  PRINCIPLES   AND   TECHNIC    OF  OPERATIONS 
UPON  BLOOD  VESSELS, 


Columbia  ©nibersiitp'^ ' 


^ 


COLLEGE  OF  PHYSICIANS 
AND   SURGEONS 


Reference  Library 

Given  by 


Digitized  by  the  Internet  Archive 

in  2010  with  funding  from 

Open  Knowledge  Commons 


http://www.archive.org/details/principlestechniOOvanb 


CHAPTER  VIII 

THE   PEINCIPLES   AND    TECHNIC   OF   OPEEATIONS   UPON  BLOOD    VESSELS 

Feederick:  T.  Van  BEUnEisr,  Je. 

GENERAL   CONSIDERATIONS 

There  are  two  principles  common  to  all  vascular  surgery  whicli,  important 
as  they  are  in  general  work,  are  here  preeminent.  Cleanliness  and  gentleness 
are,  you  may  say,  the  foimdation  upon  which  rests  success  in  operations  of  this 
sort;  and  blood  transfusion,  transplantation,  and  anastomosis  of  vessels  are 
dangerous  possibilities  in  the  hands  of  one  not  thoroughly  trained  in  the  prac- 
tice of  aseptic  surgery.  Even  the  clean  and  capable  operator  finds  plenty  of 
technical  difficulties  to  be  overcome,  handling  the  narrow  tubes,  with  their 
delicate  lining  and  thin,  flaccid,  or  thick  contractile  walls ;  and  the  manipula- 
tion of  tiny  needles  and  fine  sutures,  such  as  are  generally  employed,  requires 
skill  as  well  as  good  intentions.  So  it  seems  fair  to  say  that  no  one  ought  to 
attempt  the  more  difficult  operations  upon  human  blood  vessels  without  previous 
practice  upon  animals.  And  in  this  respect  it  is  interesting  to  remember  that 
many  of  those  operations  now  usefully  employed  in  human  surgery  were 
originated  by  experimenters  on  animals ;  while  it  is  entirely  possible  that  many 
others  which  are  being  worked  out  in  the  laboratory  to-day  will,  within  a  short 
time,  become  established  procedures  in  the  operating-room. 

For  the  sake  of  simplicity  (I)  operations  upon  arteries;  (II)  operations 
upon  veins ;  and  (III)  operations  upon  capillaries  are  here  considered  in  sepa- 
rate series.  But  operations  upon  blood  vessels  are,  in  the  main,  intended  to 
accomplish  one  or  more  of  the  following  ends :  to  check  bleeding  or  interrupt  the 
circulation ;  to  obliterate  the  vessels ;  to  alter  the  blood  or  circulation  for  pur- 
poses of  depression  or  stimulation ;  to  remove  the  cause  of  circulatory  disturb- 
ances due  to  varicose  veins ;  to  restore  or  reestablish  the  circulation ;  for  drain- 
age of  tissues  or  cavities ;  to  prevent  the  dissemination  of  infection.  And  thus 
I  have,  for  the  sake  of  a  logical  arrangement,  grouped  the  various  surgical 
procedures  under  these  sub-headings. 


249 


250  OPEKATIO^S    VFO^    BLOOD    VESSELS 

SXJBGICAIi   FSOCEDUBES 


Arteries. — The  surgical  procedures  directed  against  arteries  are: 

(A)  OPEEATIONS  TO  CHECK  BLEEDING. — The  application  of ; 

1.  Postural  compression. 

2.  Bandages  and  compresses. 

3.  Digital  pressure. 

4.  Tourniquet. 

5.  Forcipressure. 

6.  Torsion. 

7.  Terminal  ligation  =],'         ^       ''' 

°  [b.  permanent. 

(B)  OPEEATIONS     TO     OBLITEEATE     THE     VESSELS.— (See     Chapter    on 
Aneurysms. ) 

(C)  OPEEATIONS  TO  EESTOEE  OE  EEESTABLISH  THE  CIECULATION 

c.   .        fa.  longitudinal  wound. 

1.  Suture-^,     ^    °  , 

[b.  transverse  wound. 

2.  Arterial  anastomosis,  end-to-end. 

a.  end-to-end. 

3.  Arteriovenous  anastomosis-  b.  end-to-side. 

c.  side-to-side. 

.       A  i.    •  1       i.'      fa.  embolus. 

4.  Arterial  section-^ ,     ,,        , 

[b.  thrombus. 

5.  Transplantation. 

II 

Veins. — The  surgical  procedures  directed  against  veins  are: 

(A)  OPEEATIONS    TO    CHECK    BLEEDING    OE    INTEEEUPT    THE    CIECULA- 
TION 

1.  Posture. 

2.  Bandage,  compresses,  and  packing. 

3.  Digital  pressure. 

4.  Torsion,  forcipressure,  and  terminal  ligation,  ligation  en  masse. 

5.  Cautery. 

(B)  OPEEATIONS    TO    ALTEE    THE    BLOOD    OE    CIECULATION    FOE    PUR- 
POSES OF  STIMULATION  OE  DEPEESSION 

1.  Intravenous  injection  (blood  serum,  etc.). 

2.  Intravenous  infusion. 

a.  artery-to-veinl  ,. 
,         .    ::        .       Uirect. 

b.  vein-to-vein    J 


3.     Intravenous  transfusion- 


c.  intermediate. 


GENERAL    CONSIDERATIONS  251 

4.  Intravenous  injection  (anesthesia,  etc.). 

5.  Venesection  (blood-letting). 

(C)     OPEEATIONS    TO    EEMOVE    THE    CAUSE    OF    CIECULATOEY    DISTUEB- 
ANCES   DUE   TO   VAEICOSE   VEINS 


(r>) 


1.     Injection. 

2.     Ligation. 

3.     Excision. 

4.     Incision. 

5.     Suture. 

OPEEATIONS    TO 

EESTOEE 

OE    EEESTABLISH    THE    CIEOULATION 

1.     Lateral  lis 

ation. 

2.     Suture. 

'a. 

end-to-end. 

3.     Venous  anastomosis- 

b. 

end-to-side. 

c. 

side-to-side. 

4.     Transplantation. 

(E)  OPEEATIONS  FOE  DEAINAGE  OF  TISSUES  OE  CAVITIES 

Transplantation. 

(F)  OPEEATIONS    TO    PEEVENT    THE    DISSEMINATION    OF    INFECTION 

Removal  of  septic  tlirombi. 


Ill 

Capillaries. 

— The  surgical  procedures  directed  against  capillaries  are: 

(A)     OPEEATIONS  TO  CHECK  BLEEDING 

1. 

2. 

Styptics. 
Packing. 

3. 

4. 

Cautery. 
Ligation  en  masse. 

(B)     OPEEATIONS   TO    OBLITEEATE    THE   VASCULAE    CHANNELS 

1. 
2. 
3. 
4. 

Acupuncture. 
Galvanopuncture. 
Injection. 
Freezing. 

5. 

Excision  en  masse. 

6. 
7. 

Desiccation,  Kromayer  light. 
Ligation. 

IV 

Lymphatics. — Ilandley's  operation  is  here  introduced  for  the  sake  of  its 
relation  to  blood  vascular  operations. 

ANATOMICAL    POINTS    TO    BE    NOTED 

It  is,  of  course,  essential  for  the  surgeon  operating  to  have  very  definitely 
in  mind  those  muscular  and  bony  prominences  w^hich  serve  to  indicate  upon  the 


252 


OPERATIOiTS    UPOK    BLOOD    VESSELS 


WII/)jl)i/ll)lilJllli)li 


Fig.  2. 


-Sebrefines  with  Smooth 
Blades. 


Fig.  1. — Threaded  Needle  Mounted  on 
Slip  of  Paper  for  Convenient  Hand- 
ling. Dotted  lines  show  where  paper  may 
be  folded. 


Fig.    3. — Chile's    Clamps. 


Fig.  4. — Dorrance  Clamp. 


surface  of  the  skin  an  imaginary  projection  of  the  particular  vessel  toward 
which  his  attentions  are  directed ;  and  it  is  almost  as  necessary  that  he  be  thor- 
oughly familiar  with  the  relations  borne  toward  this  structure  by  the  veins, 
nerves,  muscles,  tendons,  and  fascial  planes  which  accompany  or  surround  it. 
The  neat  and  careful  exposure  of  a  blood  vessel  at  a  predetermined  point  in  its 
course  is  quite  a  different  procedure  f torn  the  often  somewhat  headlong  opening 


GENERAL    CONSIDERATIOITS 


253 


of  the  peritoneal  cavity,  in  which  the  exploring  hand  may  palpate,  i£  the  in- 
cision be  long  enongh,  almost  every  strnctnre  from  the  xiphoid  to  the  cul-de-sac 
of  Douglas.  Skin  and  fascial  planes  should  be  cleanly  and  sufficiently  divided 
for  proper  retraction  without  undue  tension  of  the  parts.  ]\Iuscles  should  be 
separated,  when  that  is  possible,  at  their  in- 
termuscular fascial  planes,  or  split,  if  it  be 
necessary,  in  the  direction  of  their  fibers.  In 
a  word,  it  is  imperative  to  avoid  any  unneces- 
sary trauma  whose  resultant  bleeding  may 
obscure  the  vessel  sought,  or  whose  tissue  de- 
struction may  endanger  the  success  of  the 
operation   by   inviting   to    subsequent   blood 

clotting  and  infection.  To  accomplish  this  an  accurate  knowledge  of  the  site 
and  relations  of  the  vessel  to  be  attacked  must  be  obtained  before  any  operation 
is  attempted.  Moreover,  there  should  be  a  clear  understanding  of  the  structure 
of  a  vessel  wall  and  the  way  in  which  a  vessel  will  behave  if  bruised,  wounded, 
or  divided. 


Fig.  5.- 


Sekrefine   with   Tape   or 
Gauze  Strip. 


INSTRUMENTS    USED 


Besides  the  ordinary  outfit  of  scalpels,  dissecting  forceps,  scissors,  retractors, 
hemostatic  forceps,  etc.,  certain  instruments  and  apparatus  of  a  special  nature 
are  required:  (A)  to  control  the  flow  of  blood  temporarily;  (B)  to  facilitate 
the  approximation  and  adjustment  of  the  vessel  seginents,  or  potentially  con- 


FiG.  6. — Jeger's  Clamps,  Straight  and  Curved. 


254  OPERATIONS    UPON"    BLOOD    VESSELS 

nect  them;  (C)  to  maintain  the  apposition  of  the  vessel  ends  or  edges  until 
cellular  repair  has  established  itself;  (D)  special  instruments  for  excision  of 
veins. 

The  first  group  (A)  includes : 

(1)  Elastic  constrictors,  linen  tapes,  or  strips,  or  heavy  twisted  silk,  fast- 
ened by  forceps  or  serrefines. 


^  iUllllllllllllllllllllllllllllilll  -!> 

Fig.  7. — Fine  Scissors  and  Forceps,  Straight  and  Curved. 

(2)  Broad-bladed,  delicate  Billroth  forceps;  miniature  Doyen  hysterectomy 
clamps  (Dorrance)  (Fig.  4);  Herrick's  clamps;  Crile's  clamps  (Eig.  3); 
serrefines  with  smooth  blades  (Fig.  2)  ;  Jeger's  clamps,  straight  and  curved 
(Fig.  6). 

Among  the  second  group  (B)  are: 

(1)  Fine  thumb  forceps  (Fig.  Y). 

(2)  Fine  scissors  (Fig.  Y). 

(3)  Various  individual  implements  such  as  Payr's  magnesium  rings; 
Murphy's  forceps ;  Crile's  and  Elsberg's  cannula ;  Brewer's  tubes ;  Lindemann's 
syringes;  Curtis  and  David's  container,  etc.,  which  will  be  described  each  in 
connection  with  its  appropriate  operation. 

The  third  group  (C)  comprises: 

(1)  Fine  needles,  curved  and  straight  (N^o.  12  to  Xo.  16). 

(2)  Fine  sutures  of  catgut,  Pagenstecker  linen  or  very  fine  silk  (first 
choice)  (Fig.  1).  Carrel  uses  special  Lyons  silk;  Lilienthal  uses  ^o.  000  silk; 
Dorrance  uses  JN^o.  1  Pagenstecker  linen ;  Guthrie  uses  No.  12  to  16  needle  from 
Kirby,  Beard  &  Co.,  Ravenhurst  Works,  Bradford  St.,  Birmingham,  and  silk 
from  James  Pearsall  &  Co.,  71  Little  Britain,  London,  or  ''Bead  silk,"  whole 
for  large,  and  untwisted  for  small  vessels. 


OPEEATIONS    UPON    ARTERIES  255 

The  last  group  (D)  includes  such  individual  instruments  as  Mayo's  dis- 
sector, Mamourian's  probe,  etc.,  which  will  be  mentioned  more  fully  later. 

METHODS  AND  CHOICE  OF  METHODS 

There  have  been  published  so  many  methods  of  undertaking  the  various 
surgical  procedures  upon  the  blood  vessels,  and  comparatively  so  few  statistics 
have  been  gathered  during  the  short  time  in  which  this  class  of  work  has  been 
at  all  extensively  practiced,  that  only  those  ways  of  proven  value  will-  be  fully 
described,  others  being  mentioned  (with  reference)  for  the  convenience  of  the 
reader. 

The  choice  of  a  method  naturally  depends  somewhat  upon  the  chooser's 
individuality,  if  not  peculiarities ;  but,  generally  speaking,  that  method  should 
be  the  choice  which  promises  to  fulfil  for  the  procedure  in  question  the  greatest 
number  of  the  following  desiderata:  (1)  safety,  (2)  speed,  (3)  ease,  (4) 
simplicity. 


DANGERS   AND    DIFFICULTIES:    CAUSES    OF    FAILURE:    COMPLICATIONS: 

RESULTS 

The  dangers  and  difficulties,  the  causes  of  failure,  the  complications  and 
results  of  operations  upon  the  blood  vessels  can  best  be  detailed  in  connection 
with  each  operation,  but  it  may  be  said  in  passing  that  escape  from  the  first 
and  excellence  in  the  last  depend  largely  upon  the  avoidance  of  dirt  and 
roughness. 


I.  OPERATIONS  UPON  ARTERIES 

OPERATIONS    TO    CHECK    BLEEDING 

POSTUKAL    CoMPKESSIOlSr 

Postural  compression  is  hardly  an  operating-room  procedure,  but  I  have 
seen  its  value  in  at  least  one  case  on  its  way  to  the  table.  A  man  with  popliteal 
aneurysm  was  wheeled  into  the  City  Hospital  at  Blackwell's  Island.  As  he  was 
being  transferred  from  chair  to  stretcher  the  aneurysm  ruptured  through  the 
overlying  skin  and  he  would  probably  have  bled  to  death  then  and  there  had 
not  an  unusually  intelligent  assistant  flexed  the  leg  sharply  upon  the  thigh 
with  a  folded  towel  at  the  bend  of  the  knee.  This  checked  the  bleeding  suffi- 
ciently to  allow  time  to  find  and  apply  a  tourniquet  and  get  the  patient  to  the 
operating-room,  which  was  at  some  distance.  In  a  similar  fasliion,  with  a  pad 
between,  complete  flexion  of  the  hip  or  elbow  joints,  and  adduction  of  the 
shoulder  joint  will  exert  obliterative  pressure  upon  the  adjacent  vessels. 


256  OPERATIOXS    UPOX    BLOOD    VESSELS 

Banda-Ges  a:^!)  Compresses 

A  stout  rubber  bandage,  witli  a  gauze  compress  beneatb  it,  may  be  used  to 
control  arterial  circulation  or  to  check  arterial  bleeding,  but  it  is  far  inferior  to 
the  regTilar  elastic  or  pneumatic  tourniquet  and  the  compress  has  to  be  ac- 
curately placed  over  the  vessel  to  make  it  properly  effective. 


Digital  Peessuee 

Digital  compression  is  little  used  now,  except  for  the  temporary  closure  of  a 
divided  vessel  until  a  clamp  can  be  applied,  or  to  control  the  circulation  in  an 
emergency,  or  for  special  operations,  as  in  MacEwen's  method  of  aortic  com- 
pression. 

The  Totjexiquet 

The  tourniquet  is  used,  in  the  operating-room,  chiefly  to  control  the  cir- 
culation; 1,  preceded  by  the  application  of  an  Esmarch  or  Martin  bandage, 
to  secure  a  bloodless  field  for  difficalt  and  careful  dissection  of  complicated 
structures,  such  as  tendons,  etc.,  at  wrist  or  ankle ;  2,  to  prevent  loss  of  blood 
in  preparing  for,  or  performing,  the  amputation  of  an  extremity. 

There  are  two  satisfactory  forms  of  tourniquet:  (a)  the  solid  rod  or  tube  of 
elastic  rubber,  about  2  feet  long  and  i/o  inch  in  diameter,  and  (b)  the  pneumatic 
tourniquet  [Perthes]  with  metal  reenforcement,  a  smaller  form  of  which  has 
been  much  used  in  connection  with  blood  pressure  testing.  A  description  of 
the  instrument  will  be  found  in  the  chapter  on  Amputations. 

Trendelenburg's  pin,  Varick's  modification  of  it,  Thomas's  forceps,  Wyeth's 
pins,  Jordan-Lloyd's  tourniquet,  Romberg's  tube,  etc.,  are  special  implements 
best  described  in  connection  with  the  operations  (amputation  of  hip  and  shoul- 
der) they  were  designed  for. 

The  Esmarch  method  of  applying  the  tourniquet  consists  in  applying 
tightly,  from  below  upward,  in  an  even  spiral,  witliout  reversing,  an  elastic 
rubber  bandage  which  is  carried  as  high  on  the  limb  as  necessary.  Immediately 
above  it  an  elastic  rod  or  tube  is  then  wound  around  the  limb  sufiiciently  tight 
to  arrest  all  arterial  circulation  below.  Thus  the  limb  is  emptied  of  blood  and 
kept  so.  The  tourniquet  is  then  fastened  by  clamp  or  tying  and  the  bandage 
removed  from  above  doT\Tiward.  Instead  of  the  preliminary  bandaging  the 
limb  may  be  emptied  of  blood  by  elevation  for  3  minutes,  while  massage  to- 
ward the  trunk  of  the  body  is  practiced. 

^latas  utters  the  following  warnings  anent  the  use  of  the  tourniquet  and 
the  elastic  bandage : 

Always  apply  the  elastic  tourniquet  over  the  femoral  or  humeral  shaft,  or  at  such 
points  that  no  vessel  can  escape  a  circumferential  compression. 

Begin  by  compressing  the  vascular  or  adductor  side,  leaving  the  outer  or  extensor 


OPERATIONS    UPON    ARTERIES  25Y 

surface  of  the  limb  free  from  pressure,  so  that  venous  choking  of  the  limb  may  be 
avoided. 

Separate  each  turn  of  the  constrictor  by  an  intervening  space  to  distribute  the 
pressure. 

Do  not  allow  the  constricted  member  to  be  suddenly  flexed  or  extended  after  the 
constrictor  is  in  place  for  fear  of  tearing  subcutaneously  the  vuiderlying  muscles  and 
nerves. 

Do  not  keep  the  constrictor  in  place  much  longer  than  an  hour,  or  an  hour  and 
a  half. 

It  has  been  objected  with  good  reasons  that  the  ischemia  of  a  limb  obtained  by 
forcible  elastic  compression  is  likely  to  be  followed  by:  (1)  Excessive  capillary  oozing; 
(2)  it  increases  the  risk  of  septic  embolism  and  of  cancerous  metastases;  (3)  it  greatly 
favors  the  absorption  of  toxic  chemical  antiseptics;  (4)  it  increases  the  liability  to 
ischemic  necrosis. 

For  this  reason  Matas  thinks  elevation  and  massage  preferable  to  the  elastic 
compression  bandage  as  a  preliminary  to  the  application  of  the  tourniquet. 

The  pneumatic  constrictor  is  made  to  encircle  the  limb  at  a  convenient 
point  proximal  to  the  intended  field  of  operation  after  preliminary  elevation 
and  massage,  unless  this  is  contra-indicated.  It  is  then  fastened  snugly,  but 
not  tightly,  by  its  metallic  ring,  and  the  pneumatic  circlet,  which  surrounds 
the  limb  inside  the  metal  reenforcement,  inflated  by  means  of  its  pump  until 
the  pulse,  palpated  at  some  point  distal  to  the  constrictor,  is  completely  oblit- 
erated.    This  usually  requires  a  pressure  of  150  to  200  mm.  of  mercury. 

The  only  bad  results  to  be  feared  from  the  application  of  the  tourniquet 
are  temporary  pressure  paralysis  and  injury  of  diseased  vessels  at  the  point  of 
application.  This  should  be  kept  in  mind  and  the  tourniquet  must  be  applied 
only  with  sufficient  force  to  obliterate  the  pulse,  which  should  be  under  the 
finger  of  an  assistant  during  the  application.  In  cases  where  the  arteries  are 
stiff  and  presumably  fragile  digital  pressure  control  of  the  circulation  is  prob- 
ably safer.  The  pneumatic  constrictor  has  this  advantage  over  the  elastic 
tourniquet,  that  its  pressure  can  be  very  carefully  and  easily  graduated,  but  the 
simplicity  of  the  elastic  band  has  so  far  brought  it  into  common  use.  Either 
one  properly  applied  is  safe  and  of  great  convenience. 


FOECIPRESSTJRE 

Practically  the  only  method  now  used  in  operation  wounds  of  checking  ar- 
terial hemorrhage  is  forcipressure,  with  or  without  subsequent  ligation,  and 
this  is  true  of  accidental  wounds  when  instruments  are  at  hand.  In  deep 
wounds  where  ligation  is  dangerous  on  account  of  the  fragility  of  the  tissues,  or 
impossible  because  of  the  narrow  space,  the  forceps  may  be  left  on  the  vessel 
for  from  24  to  48  hours  until  the  formation  of  a  firm  clot  and  the  contraction 
of  the  crushed  inner  coats  provides  for  sealing  of  the  vessel.  Wherever  pos- 
sible, ligation  should  follow  the  application  of  the  hemostatic  clamp,  unless  the 
vessel  is  of  very  small  caliber,  when  many  operators  crush  or  twist  it  (and  trust 
18 


258  OPERATIONS    UPON    BLOOD    VESSELS 

to  luck  that  the  retraction  and  torsion  of  the  inner  coat  will  suffice) .  Ligation 
is  safer,  however,  if  you  are  sure  that  your  ligatures  are  sterile. 

It  is  important  that  no  extraneous  tissue  be  seized  in  the  clamp  with  the 
artery,  lest  nerve  fibers  be  accidentally  crushed  or  included  in  the  ligature  and 
so  give  rise  to  subsequent  pain  or  possibly  paralysis. 

Hemostatic  forceps,  or  artery  clamps,  as  they  are  usually  called,  are  made 
in  various  sizes,  weights,  and  patterns,  but  the  crushing  principle  is  the  same  in 
all  of  those  designed  for  permanent  hemostasis.  They  consist  essentially  of  a 
pair  of  jaws  whose  opposed  surfaces  are  serrated,  attached  to  handles  with  rings 
at  the  end  for  a  thumb  and  finger.  They  are  provided  with  a  ratchet  lock  to 
hold  them  in  adjustment  at  the  desired  tension.  The  jaws  may  be  long  or 
short,  broad  or  narrow,  and  blunt  or  narrow-ended,  and  some  have  tiny  inter- 
digitating  teeth  at  the  tip. 

The  forceps  is  held  by  the  thumb  and  index,  or  thumb  and  middle  finger 
(usually  of  the  right  hand),  the  wound  edges  separated  and  the  tissues  around 
the  bleeding  vessel  steadied  by  the  opposite  hand,  and  the  end  of  the  divided 
vessel  is  caught,  as  cleanly  as  possible,  in  the  tip  of  the  jaws  of  the  forceps, 
which  is  thereupon  closed  and  locked  with  sufficient  force  to  hold  the  vessel 
securely.  The  handle  of  the  clamp  is  held  vertical  until  the  ligature  has  been 
passed  around  it  and  then  depressed  to  raise  the  tip  so  that  the  ligature  may  be 
tied  beneath  it.  After  the  first  knot  of  the  ligature  has  been  tied  the  handles 
of  the  forceps  are  pinched  slightly  together  and  separated-  laterally  to  unlock 
the  catch,  and  the  jaws  are  carefully  opened  and  withdrawn  from  the  wound. 

The  end  of  the  vessel  may  be  cut  through  and  pulled  away  before  the 
ligature  is  properly  applied  if  too  much  force  is  used  in  pinching  the  vessel 
and  pulling  upon  it.  Nerves  may  be  included  and  injured  if  the  artery  is  not 
grasped  free  from  its  surrounding  tissues. 

Torsion 

Some  operators  draw  the  vessel  a  short  distance  from  its  sheath,  steady  it  in 
thumb  forceps  beyond  the  hemostat,  and  twist  the  end  by  rotating  it  three  or 
four  times  on  its  own  long  axis  to  rupture  and  cause  retraction  of  the  inner 
coat.     This  is  permissible  only  with  very  small  arteries. 

LiGATIOlSr 

Terminal  ligation  is  far  the  best  means  of  permanently  arresting  arterial 
bleeding.  It  may  be  used  in  a  modified  form  to  control  the  circulation  tempo- 
rarily, and  will  be  described  in  connection  with  suture  of  arteries.  No.  2 
catgTit  is  the  most  commonly  used  material  for  tying  superficial  vessels  in  soft 
tissue.  In  firmer  tissue,  like  those  of  the  scalp,  a  stronger  gut  may  be  required. 
Eor  ligating  large  arteries  No.  3  or  No.  4  chromic  catgut  is  often  used  and  silk 
and  linen-  occasionally  also. 


OPERATIOXS    UPON    ARTERIES  259 

The  artery  to  be  ligated  is  caught  by  a  hemostat  as  described  in  the  pre- 
ceding section.  The  ligature  is  so  handed  by  the  nurse  that  it  may  be  grasped 
near  the  middle  by  the  surgeon's  right  hand.  He  passes  it  round  the  vessels 
from  right  to  left,  catching  the  free  end  in  his  left  hand,  ties  a  single  knot, 
setting  it  down  firmly  upon  the  vessels  beyond  the  tip  of  the  clamp.  The  as- 
sistant then  removes  the  clamp  and  the  surgeon  ties  a  secure  knot  in  such 
fashion  as  to  form  what  is  generally  known  as  a  "square"  or  "reef"  knot,  which 
is  less  bulky  than  the  "surgeon's"  knot,  and  safer  than  the  "granny."  Care 
must  be  taken  to  set  the  second  knot  down  tightly  upon  the  first  and  not  to 
"upset"  the  knot.  If  too  much  force  is  used  in  tying  the  first  knot  the  vessel 
may  be  cut  too  deeply  and  the  closure  be  made  less  secure.  It  is  not  uncommon 
to  see  a  surgeon  in  a  hurry  pull  too  hard  on  his  ligature  while  tying  a  delicate 
vessel,  and  tear  the  end  of  the  vessel  off,  necessitating  a  repetition  of  the  pro- 
cedure. 

OPERATIONS    TO    RESTORE    OR    REESTABLISH    THE    CIRCULATION 

Lateral  Suttjke 

Lateral  suture  of  an  artery  may  be  required  to  repair  an  accidental  wound  or 
rupture,  either  longitudinal  or  transverse,  or  an  incision  that  has  been  made  by 
the  surgeon  to  remove  an  embolus.  It  should  not  be  used  in  wounds  of  such 
size  that  their  closure  will  occlude  the  artery,  nor  in  cases  of  extensive  crushing 
of  the  artery  and  perivascular  tissues.  The  presence  of  infection  also  contra- 
indicates  it.  The  essential  conditions  for  the  operation  are:  the  best  possible 
asepsis,  a  non-injurious  means  of  temporary  hemostasis,  gentleness  in  handling 
the  vessels,  accurate  approximation  of  the  intimas  without  unnecessary  trauma, 
means  of  maintaining  this  approximation  until  cellular  repair  has  been  estab- 
lished. 

The  part  should  be  shaved  and  wrapped  in  a  soap  poultice  for  24  hours  if 
possible;  then  scrubbed  with  a  gauze  compress  with  green  soap  and  sterile 
water;  then  with  alcohol  and  ether  and  a  gauze  compress;  then  flushed  with 
mercuric  chlorid,  1 :  5,000,  and,  finally,  sterile  normal  saline.  The  surface 
landmarks  that  indicate  the  line  of  the  vessel  to  be  attacked  must  be  noted  and 
the  line  marked  upon  the  skin  by  a  light  stroke  of  the  scalpel. 

Equipment. — Beside  the  usual  equipment  of  scalpels,  dissecting  scissors 
and  forceps,  hemostats  and  retractors,  ligatures  and  sutures  and  needles,  there 
are  required:  several  serrefines  with  rubber-covered  or  smooth  blades  (Fig. 
2)  ;  1  pair  of  fine,  straight  scissors;  1  pair  of  fine,  curved  scissors;  1  pair  of 
fine,  straight  forceps;  1  pair  of  fine,  curved  forceps  (Fig.  7);  several  fine 
hemostats  (mosquito  clamps)  ;  a  jar  of  sterile  albolin  with  eye-dropper;  and 
several  fine  needles,  ISTo.  12  to  No.  16,  threaded  with  fine  silk  (Fig.  1),  which 
should  be  boiled  in  albolin. 

Operative  Steps. — The  operative  steps  are  as  follows:     (1)  Control  the  flow 


260 


OPEKATIOXS    UPOX    BLOOD    VESSELS 


of  l)iood  through  the  artery  bv  tourniquet,  if  possible.  (2)  Expose  the  artery 
by  sharp  and  blunt  dissection,  using  every  effort  to  avoid  unnecessary  tissue 
injury  and  bleeding,  and  fasten  towels  to  the  edge  of  the  skin.      (3)   If  the 


Fig.  8. — Suture  of  Longitudinal  Wound  in  Blood  Vessel:  Guthrie's  Position  of  Hands. 


artery  is  bleeding  when  exposed,  an  assistant  should  exert  pressure  upon  it 
above  and  below  the  wound,  or,  if  necessary,  with  a  finger  upon  the  wound 
until  it  can  be  sufficiently  isolated  from  its  bed  to  occlude  it  temporarily  by 
tape  or  clamps  (Fig.  5)  about  1  inch  above  and  below  the  wound.  (4)  Ke- 
move  all  blood  and  blood  clots  from  the  wound  by  sponging  with  sponges  damp- 
ened in  warm  normal  sa- 
line; and  from  the  vessel 
lumen,  by  very  gently 
stripping  it  toward  the 
wound  from  both  ends,  the 
expressed  blood  being  ab- 
sorbed by  a  dry  sponge 
held  against  the  wound. 
(5)  Handle  the  vessel 
with  the  fingers  (see  Figs. 
8  and  9)  rather  than  with 
the  forceps,  and  as  gently 
as  possible.  (6)  Pick  up, 
in  fine  forceps,  the  deli- 
cate outer  coat  of  the  vessel  and  trim  it  away,  from  the  margins  of  the  wound 
for  1  or  2  mm.  (1/25  to  1/12  inch)  with  fine  scissors.  (7)  If  the  wound  edges 
in  the  vessel  are  lacerated  or  contused,  trim  them  smooth  with  fine,  sharp 
scissors.  (8)  Take  a  few  drops  of  sterile  liquid  albolene,  on  the  tip  of  a  pair 
of  forceps  or  in  a  hypodermic  syringe  and  gently  moisten  the  wound  edge 
with  it.  If  the  sutures  have  not  been  boiled  in  albolene,  lower  them  carefully 
in  the  jar  until  they  are  completely  saturated  with  it.     (9)  A  continuous  over- 


FiG.  9. 


-Suture  of  Transverse  Wound  in  Blood  Vessel: 
Holding  Vessel  on  Finger. 


OPERATIONS  UPON  AETERIES 


261 


hand  (Fig.  1-i)  or  interrupted  suture  may  be  done,  or  a  lock  stitch  (Fig.  11), 

and  should  pass  through  all  coats,  taking  care  not  to  touch  the  intima  with  the 

needle,  except  at  the  point  of  puncture.     The  edges  of  the  wound  should  be 

brought  into  close  apposition  without  inverting, 

wrinkling,  or  puckering,  and  the  suture  must 

not  be  so  tight  as  to  cut  through  the  tissue.    The 

needle  should  be  introduced  about  I/2  to  1  mm. 

from  wound  edge  and  stitches  should  be  placed 

about  1^  to  1  mm.  (1/50  to  1/25  inch)   apart 

and  the  ends  tied  with  a  square  knot  and  cut  off 

short. 

(10)  A  continuous  mattress  suture  (Fig. 
12)  is  recommended  by  Dorrance  and  inter- 
rupted mattress  sutures  (Brian  and  Jaboulay) 
have  been  used  (Fig.  13)  by  Archibald  Smith 
with  satisfactory  results.  Stewart's  clamp  may 
be  employed  if  it  is  thought  unwise  to  interrupt 
the  circulation  (Fig.  10).  When  the  suture  is 
completed,  remove  the  distal  clamp  or  tape  and 
look  for  leakage  at  the  suture  line.  If  any  oc- 
curs, press  lightly  upon  the  vessel  with  an  ab- 
sorbent gauze  sponge  for  a  minute.     Otherwise, 

loosen  the  proximal  clamp  or  tape  and  allow  the  full  blood  stream  to  pass  the 
suture  line.  If  slight  leakage  occurs,  press  lightly  with  a  sponge,  as  before, 
■until  it  ceases.  If  it  cannot  be  so  controlled,  within  3  or  -1  minutes,  or  if  a 
spurting  point  is  seen,  replace  the  tape  or  clamps  to  control  the  bleeding,  care- 
fully sponge  away  the  blood  and  introduce  as  many  extra  sutures  as  necessary  to 


Fig.  10. — Stewart's  Clamp  for 
Isolating  Portion  of  Lumen 
OF  Vessel. 


Fig.   11. — Lateral  Suture  of  Longitudinal  Wound  with  Lock  Stitch,  Using  Tension 

Sutures. 


close  the  defect  in  the  original  suture  line.  Then  remove  clamps  as  before.  If 
the  suturing  has  been  carefully  done  there  will  be  very  little  leakage  and  this 
will  cease  within  a  few  minutes  as  soon  as  fibrin  blocks  the  hole  around  the 
punctures.     Then  close  the  wound  of  exposure  in  the  usual  manner. 

The  dangers  of  this  operation  are  not  great,  if  you  can  be  sure  of  aseptic 


262 


OPERATIONS    UPOIsT    BLOOD    VESSELS 


Fig.   12. — Dorrance  Suture  of  Trans 
VERSE  Wound. 


conditions,  gentle  handling  and  proper  instruments.     But  the  difficulties  are 

considerable ;  for  it  is  not  easy  to  get  a  good  exposure  of  the  vessel  and  collateral 

branches  are  apt  to  complicate  the  control 
of  the  blood  current.  If  they  are  small, 
they  may  be  ligated;  but,  if  large,  it  is 
better  to  isolate  them  sufficiently  to  close 
them  temporarily  with  tapes  or  serrefines. 
Again,  the  fine  needles  are  not  easy  to  hold 
and  manipulate  and  the  sutures  break  very 
easily,  if  they  are  not  tied  with  the  utmost 
care. 

The  chief  cause  of  failure  is  occlusion 
of  the  artery  by  thrombus  formation. 
Secondary  hemorrhage  may  occur  from 
tearing  out  sutures,  or  following  infection, 
if  the  sutures  are  not  properly  placed  or 

asepsis  is  imperfect,  but  it  is  not  likely  to  happen  and  only  occurred  once  among 

the  cases  reported  up  to  1912. 

The  results  are  generally  good  in  the  reported  cases  as  to  function,  but  doubt 

remains  as  to  permanent  patency  of  lumen. 

'i/niif//f//m//m//////////// ■ 

AeTEBIAL   AlS^ASTGMOSIS 

Circular  suture  of  arteries  may  be  called 
for  where  a  (1)  transverse  wound  divides 
more  than  one-half  of  the  lumen  of  an  artery ; 
(2)  where  the  lateral  suture  of  a  gaping  de- 
fect in  the  wall  would  occlude  the  vessel,  or 

where  crushing  of  the  artery  necessitates  considerable  resection  of  the  wound 
edges;  (3)  where  the  artery  has  been  completely  divided  by  knife,  bullet,  or 
other  injury;  (4)  after  excision  of  a  segment  for  aneurysm,  new  growth,  or  for 

extensive  crushing  of  an  artery. 

. /      Arterial   circular   suture   is 

^^^^\^^^^^^^W\w^^^^>;i2i^\\^\\^^^  eontra-indicated    (  1  )    i  n   a  1 1 

smaller  arteries  whose  col- 
lateral circulation  is  normally 
sufficient  to  maintain  nutrition 
of  limb,  etc.,  after  ligation;  (2) 
in  all  crushed  and  lacerated 
wounds  when  all  the  perivascu- 
lar tissues  are  badly  or  irreparably  injured;  (3)  in  all  suppurating,  or  other- 
wise infected  wounds  on  account  of  thrombosis  and  secondary  hemorrhage; 
(4)  in  all  cases  where  approximation  cannot  be  obtained  without  overstretching 
of  vessels  and  where  venous  grafting  or  substitution  is  impossible.     (Matas.) 


Fig.  13. — Bbiau-Jaboulat  Intbbbupted 

Suture. 


Fig.   14.- 


-Lateral  Suture  with  Continuous  Over- 
hand Stitch. 


OPERATIONS  UPON  ARTEEIES 


263 


Instruments. — The  instruments  required  are:  Usual  dissecting  set;  elastic 
constrictors;  Langenbeck's  serrefines  (or  serreplats)  ;  miniature  Doyen  clamps 
with  elastic  covering;  selection  of  Payr's  magnesium  rings  (Fig.  20);  fine 
forceps,  straight  or  curved ;  fine  scissors,  straight  or  curved ;  finest  silk  or 
Alsace  thread  (No.  500)  v^'ith  Kirby  No.  16  straight  needle  (for  small  ves- 
sels) ;  fine  cambric  needles,  or  floss  needles,  No.  6  to  No.  10,  with  No.  0  or 
No.  1  oculist's  silk  (for  larger  vessels);  sterile  albolin;  black,  lint-free  field 
sheet,  or  a  white  field  sheet,  if  black  sutures  are  used;  skin  clips  to  fasten  it 
to  wound  edges. 

Methods. ^ — A  considerable  number  of  methods  of  end-to-end  anastomosis  of 
arteries  have  been  reported,  but  up  to  the  present  time  only  three  have  been  ex- 
tensively used:  (1)  The  invagination  method  (Murphy,  Payr,  etc.)  ;  (2)  broad 
marginal  apposition  (Salomoni,  Brian,  Jaboulay,  Lespinasse  and  Eisenstaedt)  ; 

(3)  direct  marginal  approximation  (Carrel,  Guthrie,  etc.).  In  all  of  them  the 
chief  points  of  technic  are:  Complete  asepsis,  exposure  of  vessels  with  least 
possible  injury,  temporary  interruption  of  blood  current,  control  of  vessel  while 
applying  suture,  accurate  approximation  of  the  walls,  perfect  hemostasis  by 
pressure  after  removing  clamps,  careful  toilet  of  the  wound. 

INVAGINATION  METHOD. — The  invagination  method  is  said  to  be  "ap- 
plicable to  all  vessels  of  large  caliber,  including  popliteal  and  femoral,  in  which 
not  more  than  three-quarters  of  an  inch  have  been  removed  by  injury  or  ex- 
cision." If  position  of  limb  can  be  made  to  relieve  tension  possibly  a  greater 
loss  than  three-quarters  of  an  inch  can  be  permitted  without  grafting. 

MUEPHY'S  METHOD. — The  steps  of  Murphy's  original  invagination  method 
are: 

(1)  Expose  by  a  generous  incision  and  isolate  the  artery  from  its  sheath  for 
a  distance  of  at  least  1 
inch  above  and  1  inch  be- 
low injury.  If  collateral 
branches  interfere,  ligate 
or  temporarily  clamp 
them.  (2)  Apply  serre- 
fines or  rubber-covered, 
flexible-bladed  clamps  at 
upper  and  lower  ends  of 
isolated  portion  with  just 
enough  pressure  to  stop 
bleeding.  (3)  Excise 
crushed  portion  of  vessel 
(up  to  %  inch),  or  trim 

edges  with  sharp  scissors,  if  lacerated  or  uneven.  Pull  adventitia  over  end  of 
stumps  and  cut  off  with  sharp  scissors  (Eig.  15),  and  remove  all  blood  and  clots. 

(4)  Incise  distal  stump  longitudinally  a  short  distance  with  sharp  knife  (Eig. 
16).     (5)  Place  three  U-shaped  traction  sutures,  at  equidistant  points,  through 


Fig.  15. — Cutting  Off  the  Adventitia. 


264 


OPERATIONS    UPOAT    BLOOD    VESSELS 


^iniiivuuM 


Fig.   16. — Murphy's  Earlier    Method  ; 
Traction  Sutures  Introduced. 


all  coats  but  intima,  of  the  proximal  stump,  a  short  distance  (about  ^4  inch) 
from  its  cut  end.     ( 6 )  Thread  the  free  ends  of  these  sutures  in  separate  needles 

and  pass  them  from  within  outward, 
through  all  coats  of  distal  stump  about 
^  inch  from  its  cut  edge  at  points  cor- 
responding to  those  on  proximal  stump 
(Fig.*  16).  (7)  By  the  aid  of  these  as 
tractors,  and,  if  necessary,  with  an  as- 
sistant manipulating  the  stumps,  the 
proximal  is  invaginated  into  the  distal  end  and  the  traction  sutures  tied  on  the 
surface  of  the  distal  stump.  (8)  The  joint  is  then  reinforced  by  several  inter- 
rupted non-penetrating  sutures  on  outer  surface  of 
junction  of  the  stumps  or  by  a  continuous  suture 
(Fig.  17). 

Murphy's  more  recent  technic  includes  the  use 
of  a  specially  devised  instrument,  a  sort  of  split,  hol- 
low, open-ended  cylinder,  with  separable  halves,  car- 
ried on  a  handle.  The  distal  stump  is  cuffed  back- 
ward over  this,  the  cut  end  of  the  proximal  stump 

sutured  to  the  reflection  and  the  cuff  then  turned  forward  over  the  prox- 
imal stump   and   sutured  in   place    (Fig.    18).      This  was   devised   for  end 


-lAiiiiM^&MLiiiiiii^. 

Fig.   17. — Murphy's  Earlier 
Method;        Invagination 
Completed    by    Circular 
Suture. 


Fig.   18. — Murphy's  Recent  Method  of  End-to-end  Anastomosis  by  Invagination. 

to-end  arterio-venous  anastomosis.     Modifications  of  this  method  have  been 
proposed  by  Bougie,  Jensen,  O'Day  and  others. 

Payk's  Method. — Payr's  method  of  in- 
vagination utilized  a  magnesium  ring  to 
maintain  the  lumen  size  of  the  invaginated 
portion  (Fig.  20).  Hoepfner's  modification 
of  Payr's  method  (1)  exposes  and  isolates  the 
artery  sufficiently  to  apply  clamps  well  be- 
yond the  wound  or  the  portion  that  must  be 
excised;  (2)  special  curved  handle  clamps, 
with  flat  or  rubber-covered  blades  (Fig.  19),  are  then  applied  with  only  suffi- 
cient force  to  shut  off  the  blood  current;   (3)  the  adventitia  and  the  bruised 


Fig.  19. — Hoepfner-Stich  Clamp. 


OPERATIONS    UPOiNT    ARTERIES 


265 


Fig.  20. — Payk's  End-to-end  Anastomosis  with  Magnesium  Ring. 


ends  of  the  artery  are  next  trimmed  carefully  off  and  the  blood  washed  away 
with  normal  saline  solution;  (4)  the  distal  end  of  the  vessel  is  then  covered 
with  a  sponge  damp  with  saline,  while 
three  fine  silk  sutures  are  introduced  at 
the  margin  of  the  proximal  stump,  120° 
apart  through  all  coats  and  tied;  (5) 
the  ends  held  together  are  passed 
through  a  thin,  grooved  ring  of  mag- 
nesium (same  size  as  vessel),  which  is 
held  in  a  special  forceps  and  slipped, 
like  a  collar,  over  the  proximal  stump; 
(6)  by  traction  on  the  threads,  the  pro- 


truding  end  of  the   artery  is  everted, 


Fig.  21. — Jeger's  Holder  for  Payr's  Ring, 


rolled  back  over  the  ring,  tied  in  place 

by  a  fine  silk  circular  ligature,  fitting  snugly  into  the  groove,  and  the  traction 
sutures  removed ;  ( 7 )  three  similar  traction  sutures  are  now  placed  in  the  distal 
stump  to  stretch  its  margin  and  gently  draw  its  lumen  over  the  everted  cuff  of 

the  proximal  stump  where  it  is  tied  in  place  by  a  fine 
silk  circular  ligature.  This  completes  the  anastomosis, 
which  brings  intima  to  intima,  but  slightly  narrows  the 


Fig.  22. — Jeger's  Mod- 
ification OF  Payr's 
Magnesium  Cylin- 
der FOR  Deeply 
Placed  Vessels. 


lumen.      Jeger   has    devised    an   ingenious   holder   for 


Payr's  rings,  which  considerably  simplifies  the  technic 
(Fig.  21).  He  has  also  produced  a  modified  ring  or 
cylinder  which  he  recommends  for  use  in  uniting  deeply 
placed  vessels  (Fig.  22). 
METHOD  OF  BEOAD  MARGINAL  APPOSITION". — With  a  similar  end  in 
view,  of  bringing  intima  to  intima,  Salomoni  (Fig.  23),  and  also  Briau  and 
Jaboulay  (Fig.  24),  placed  their  sutures  at  a  little  distance  from  the  cut  edges 
of  the  vessel  in  such  manner  as  to  evert  these  edges  and  draw  comparatively 
broad  intimal  surfaces  of  both  stumps  into  contact.  Salomoni  used  a  simple 
interrupted  suture,  while  Brian  and  Jaboulay  employed  an  interrupted  mat- 


266 


OPERATIOIsTS    UPOi^    BLOOD    VESSELS 


tress  suture.  Dorrance,  using  Pagenstecher  'No.  1  thread,  on  the  finest  needle 
that  would  hold  it,  and  employing  special  flexible  bladed  forceps  (Fig.  4),  for 
hemostasis  devised  a  continuous  mattress  suture  (Fig.  25)  locked  at  every 
third  stitch  and  reinforced  by  a  continuous  overhand  suture  of  the  everted 
wound  margins  (Fig.  26). 


Fig.  23. — Salomoni's  Method  of  End-to-end 
Suture. 


Fig.  24. — Briau-Jaboulay  Method  of 
End-to-end  Suture. 


Fig.  25. — Dorrance's  Method  of  End- 
to-end  Suture. 


Lespinasse  and  Eisenstaedt  have  reported  a  method  of  anastomosis  of  blood 
vessels,  based  on  the  same  principle  of  broad  marginal  confrontation  of  intima. 
They  use  chemically  pure  magnesium  rings  to  facilitate  coaptation  and  com- 
paratively coarse  suture  material.     These  rings  are  "flat,  washer-like  pieces  of 

metal,  with  a  thickness  of  one  millimeter, 
and  a  wall  of  from  one  to  two  millimeters 
in  width.  On  the  wall,  eight  suture  holes 
are  located,  equidistantly,  which  have  been 
countersunk,  or  beveled  to  prevent  cut- 
ting of  the  sutures  when  traction  is  made 
in  tying  them.  Likewise  the  circumferen- 
tial and  luminal  edges  are  beveled  to  pre- 
vent injury  to  the  coats  of  the  vessels." 

These  are  applied  in  such  a  way  that 
when  the  final  sutures  are  tied  the  approxi- 
mated ends  of  the  vessel  are  practically  clamped  between  them  (Fig.  27).  They 
do  not  state  results,  but  conclude  that  this  "method  is  superior  because  Ist^  the 
suturing  is  not  fine ;  it  is  quite  coarse ;  2nd,  the  sutures  and  rings  are  extravascu- 
lar  and  do  not  come  in  contact  with  the  blood 
stream.  The  normal  intima  alone  comes  in  con- 
tact with  the  blood  stream  at  the  completion  of  the 
operation." 

METHOD  OF  DIRECT  MARGINAL  APPROXIMA- 
TION.— The  method  of  direct  marginal  approxima- 
tion by  continuous  through-and-through  sutures  of 
the  vessels  has  been  very  completely  developed  by 
Carrel  and  Guthrie,  whose  methods  are  practically 
the  same.  Guthrie  has  recently  published  a  very 
full  account  of  his  technic  and  results  and  the  following  description  of  Carrel's 
technic  is  abbreviated  from  onp  of  his  recent  communications. 


Fig.  26. — Dorrance's  Method. 
Mattress  Suture  Reinforced 
BY  Continuous  Overhand  Su- 
ture. 


OPERATIONS  UPON  ARTERIES 


267 


Caeeel's  Method. — General  Rules. — To  avoid  complications  of  stenosis, 
hemorrhages,  and  thrombosis:  (1)  A  rigid  asepsis  is  absohitely  essential;  an 
infection  not  sufficient  to  prevent  primary  union  of  a  wound  may  yet  cause 
thrombosis.  (2)  Blood  vessels  may  be  freely  handled  in  the  fingers,  but  not 
with  forceps ;  the  latter,  if  used,  must  take  only  the  outer  sheath  in  its  grasp, 
and  when  employed  for  hemostasis  must  have  smooth  jaws  with  carefully  regu- 


FiG.    27. — Lespinasse  and  Eisenstaedt  Method  of  End-to-end  Anastomosis,  Method  III. 

lated  pressure.  (3)  Drying  of  the  endothelium  or  the  presence  of  coagiilated 
blood,  fibrin  ferment  or  foreigTi  tissue,  or  tissue  juices  on  the  interior  of  a  ves- 
sel may  lead  to  thrombosis ;  therefore,  the  external  sheath  must  be  resected  and 
the  lumen  of  the  vessels  and  the  surrounding  parts  must  be  washed  with 


Fig.  28. — Gentile's  Syringe  (Carrel). 


Ringer's  solution  and  coated  with  vaselin.  (4)  To  minimize  trauma  of  the 
endothelium  by  the  perforating  sutures,  the  needles  and  suture  material  must 
be  of  the  smallest  size,  sterilized  in  vaselin,  and  kept  coated  with  it  during  the 
suturing.  (5)  To  avoid  stenosis,  keep  the  arterial  walls  under  lateral  tension 
by  traction  sutures  while  putting  in  the  continuous  stitch. 


268 


OPEKATIONS    UPON    BLOOD    VESSELS 


Instruments. — Crile  clamps  (Fig.  3)  or  elastic  forceps  (Eig.  4),  for  tem- 
porary hemostasia  in  large  vessels,  as  femoral  artery;  small  Crile  clamps  or 
smooth- jawed  serrefines  (Fig.  2)  without  rubber  covers,  for  small  vessels,  or 
narrow  rubber  strips  held  round  the  artery  by  serrefine  or  forceps;  Gentile 


Fig.  29. — Artery  Isolated  on  Black  Field  Sheet. 


syringe  and  Ringer's  solution  for  washing  out  the  vessels  (Fig.  28)  ;  round, 
straight  needles,  Kirby  ISTo.  16,  for  small  vessels,  ISTo.  12  to  ISTo.  16,  can  be  used 
for  large  vessels;  they  are  threaded  with  very  fine  silk  (Fig.  1)  and  sterilized 
in  vaselin;  Gentile  forceps  to  hold  the  traction  sutures;  a  black  towel  to  lay  the 

sutures  on  and  a  black  Japanese 
field  sheet  to  surround  the  wound. 
Temporary  Hemostasia  and 
Preparation  of  Vessels. — (1)  Ex- 
pose the  vessels  by  a  large  incision 
and  dissect  them  free,  securing  a 
large  operating  field.  (2)  Catch 
all  bleeding  points  and  make  the 
wound  as  "dry"  as  possible.  (3) 
Cause  temporary  hemostasis  of  the 
artery  by  clamps,  forceps,  or  rub- 
ber bands  placed  a  few  centimeters 
from  the  site  of  the  future  anastomosis ;  clamping  or  ligating  all  collaterals  that 
interfere.  (4)  Resect  the  sheath,  and  trim  the  ends  of  the  vessels  as  may  be 
necessary.  (5)  Introduce  the  ends  of  the  syringe  into  the  vessels  and  wash  out 
the  blood  from  them  and  from  the  operating  field,  and  remove  the  fluid  with  dry 


Fig.  30. — Carrel's  Method  of  End-to-end  Anas- 
tomosis: Application  of  the  Two  Posterior 
Retaining  Stitches. 


OPERATIONS  UPOA^  AETERIES 


269 


gauze  and  forceps.  (6)  Coat  the  vessels  and  surrounding  parts  with  warm 
vaselin.  (7)  Place  the  black  silk  field  sheet  around  the  vessel  ends  (Fig.  29). 
Suture. — Place  and  tie  the  first  posterior  retaining  stitch  on  the  posterior 
aspect  of  the  vessels'  ends  near  the  edges.  Fix  the  short  end  in  a  small  forceps 
and  lay  the  long  end  in  the  needle  upon  the  black  towel  to  use  for  the  continuous 


Fig.  31. — Carrel's  Method:  Application  of 
Anterior  Retaining  Stitch.      ' 


Fig.  32. — Carrel's  Method:  Circum- 
ference of  Artery  Transformed 
into  a  Triangle  by  Traction  on  the 
Retaining  Stitches. 


suture.  Place  the  second  posterior  retaining  stitch  120°  from  the  first,  cut  a 
convenient  length,  and  fix  both  ends  in  a  small  forceps  (Fig.  30).  Make  a 
slight  traction  on  both  posterior  stitches  and  introduce  an  anterior  traction 
thread  equidistant  from  them  (Fig.  31). 
The  ends  of  the  artery  must  come  to- 
gether without  strong  traction. 

Convert  the  circumference  of  the  ap- 
proximated ends  into  a  triangle  by  draw- 
ing upon  the  traction  threads  (Fig.  32), 
and  unite  them  by  a  continuous  over- 
hand suture  (Fig.  33)  with  the  original 
needle  and  silk,  beginning  near  the  first 
posterior  traction  stitch  and  carrying  it 
around  the  vessel  to  the  same  point, 
squeezing  out  vaselin  before  closure  is 
completed.     Only  a  few  stitches  between 

traction  threads  are  necessary;  three,  for  example,  in  an  artery  the  size  of  a 
dog's  carotid.  Take  gi'eat  care  to  approximate  the  divided  surfaces  exactly. 
They  must  not  come  into  contact  with  the  blood  stream.  Carefully  examine 
the  line  of  suture  and  close  any  gaps  by  an  additional  stitch. 

Reestahlishment  of  the  Circulation. — Place  gauze  sponges  on  the  suture  line 
and  make  gentle  pressure  while  the  clamps  are  removed.  Expect  some  leakage 
during  the  first  minute,  but,  if  some  bleeding  persists  when  the  sponges  are 
removed,  after  two  or  three  minutes,  complementary  stitches  may  be  added. 


Fig.  33. — Carrel's  Method:  Continuous 
Suture  Almost  Completed. 


270 


OPERATIONS    UPOiST    BLOOD    VESSELS 


Then  wash  the  vessels  and  the  wound  with  Ringer's  solution,  and  close  the 

wound  without  drainage. 

Othek    Methods. — Guthrie's    technic,     as     recently     published,     differs 

somewhat  from  Carrel's  in  minor  points.     He  uses  Kirby's  needles,  ]N"o.  12  to 

JSTo.  16,  and  ''bead  silk,"  whole  for  larger  vessels,  and  untwisted  for  small.    He 

prefers  to  occlude  the  vessel  by  narrow  tapes,  held 
in  forceps  (Fig.  5),  and  he  removes  the  blood  from 
the  divided  ends  on  to  a  gauze  sponge,  by  gently 
stripping  them  between  the  fingers  instead  of  wash- 

^ ing  with  a  syringe,  and  wipes  out  his  wound  with 

i^  is^^^iimi<:^^^m^^:>mmmm!,  ^  gauze  sponge.     After  removing  the  blood,  he  ap- 

plies a  little  oil  to  the  cut  ends  instead  of  coating 
with  vaselin.  He  uses  one  posterior  and  two  an- 
terior traction  threads  instead  of  the  reverse,  and 
lightly  oils  his  fingers  before  affixing  them.  He 
places  the  stitches  of  his  continuous  suture  about 
1/2  mm.  from  the  cut  edges,  and  the  same  distance 
apart,  and  interrupts  the  circular  suture  twice  by 
tying  it  at  120°  intervals  to  the  traction  threads. 
Guthrie  says  suitable  silk  can  be  procured  from 
James  Pearsall  &  Co.,  71  Little  Britain,  London ; 
and  Co.,  Ravenhurst  Works,  Bradford  St.,  Bir- 


FiG.  34. — Correct  Direction 
OF  Needle  Introducing  Stay 
Suture.  Dotted  line  shows 
incorrect  direction. 


needles  from  Kirby,  Beard 
mingham. 

Jeger,  in  describing  Carrel's  method,  emphasizes  a  practical  point  illustrated 


Fig.  35. — Tying  the  Stay  Suture. 


in  Figure  34.  The  vertical  introduction,  rather  than  the  oblique,  of  the  needle 
through  the  vessel  wall  has  the  effect  of  slightly  everting  the  cut  edges  of  the 
vessel  segment  when  the  sutures  are  tied,  as  shown  in  Figure  35.     He  strongly 


OPEEATIO^^S    UPO^T    ARTEEIES 


271 


Fig.  36. — Angulation  of  the  Vessel  to  Facil- 
itate Insertion  of  Continuous  Suture. 


advises  against  the  use  of  forceps  and 

says   if  they   are   absolutely  necessary 

that  they  should  grasp  the  vessel  only 

between  its  cut   edges  and  the  suture 

line,  7iot  beyond  this,  so  that  the  portion 

thus  injured  shall  not  touch  the  blood 

stream.    He  recommends  angailating  the 

vessel  at  the  line  of  junction,  as  shown 

in  Fig-ure  36,  to  facilitate  the  insertion 

of  the  continuous  suture.   Like  Guthrie, 

he  ties  the  continuous  suture  to  the  ten- 
sion   suture.      He    places    his    stitches 

slightly  closer  together  than  Carrel  in 

the    continuous     suture.       If    comple- 
mentary  sutures  for  a  spurting  point 

are  necessary,  he  says  that  they  should 

embrace    all    the    coats    of    the    vessel 

(Guthrie  to  the  contrary),  lest  intima 

be  not  brought  to  intima.     If  further  sutures  are  needed  to  stop  oozing  only, 

these  he  does  not  make  through  and  through.     And  if  they  fail  to  control  the 

bleeding  he  applies  a  bit  of  muscle  to  the  place 
or  wraps  a  strip  of  fascia  or  peritoneum  around 
the  anastomosis,  as  in  Fig-ure  37.  He  calls 
suture  of  the  adventitia  superfluous.  For  deep 
vessels  he  advises  that  the  tension  sutures  be 
"U"  sutures  and  of  heavier  silk,  if  intended  for 
unusual  tension.     He  recommends  the  use  of 

Horsley's  tension  suture  holder  (Fig.  38),  or  Jeger's  instrument  (Fig.  39),  for 

the  same  purpose. 

Horsley  has  devised  an  ingenious  instrument 

for  holding  the  stay  sutures,  in  end-to-end  anas- 
tomosis   (Fig.    38) — "a   steel  shaft,    1/16    inch 

thick,  curving  at  one  extremity  into  a  shorter 

shaft    and   flattened    at    the    angle    to   make   it 

springy.     There  are  five  buttons  to  fasten  the 

thread  to."     He  employs  a  continuous  mattress 

suture  and  everts  the  edges  of  the  vessels. 

Dobrowolskaja    has    recently    experimented 

with  complicated  incisions,  in  the  effort  to  pre- 
vent narrowing  of  lumen  in  end-to-end  suture  of 

vessels  of  small  caliber.    The  indented  incision  is 

the  simplest.      This  is  made  triangular  to  the 

middle  of  the  vessel  (Fig.  40),  one  segment  rotated  90°,  and  the  long  point 

brought   together   with   stay   sutures,    leaving   wide   diamond-shaped    defects. 


Fig.  37. — Reinforcement  of  the 
Anastomosis  with  a  Strip  of 
Fascia  or  Peritoneum. 


Fig.  38. — Horsley's  Tension 
Suture  Holder. 


2Y2 


OPERATIONS    UPON    BLOOD    VESSELS 


The  edges  of  these  are  approximated  by  lateral  traction  on  the  stay  suture  and 
then  united  by  a  continuous  suture.  This  results  in  a  widening  of  the  lumen 
at  the  line  of  suture  which,  it  is  said,  shows  a  tendency  to  disappear  after  a 
while.  Human  hair  or  silk  jSTo.  00  on  straight  needle  were  used  and  it  is  said 
that  these  complicated  incisions  and  sutures  apparently  do  not  endanger  the 

vessels.  They  may  also  be  used  to  accommodate 
an  artery  to  a  larger  vein,  in  end-to-end  suture. 
O'Day  has  recently  reported  a  successful 
modification  of  Payr's  invagination  in  which 
he  used  a  circular  ligature  instead  of  a  ring,  to 
turn  back  a  cuff  on  the  proximal  segment,  and 
fastened  the  cuff  by  quadrant  sutures  tied  to  the 
ligature.  He  then  invaginated  the  proximal 
into  the  distal  stump  and  sutured  the  latter  to 
the  cuff  by  a  running  stitch.  He  draws  the 
previously  retracted  adventitia  toward  the  line 
of  union  before  removing  the  temporary  hemo- 
statics, and,  if  complementary  sutures  are  neces- 
sary, he  advises  that  they  should  include  only 
the  outer  coats. 

Choice  of  Methods. — T  h  e  invagination 
method  of  Murphy  is  objectionable  in  that  it 
narrows  the  lumen  and  shortens  the  vessel  itself 
and  is  liable  to  be  followed  by  thrombosis  because  it  leaves  a  raw  surface  in  con- 
tact with  the  blood  stream.  With  the  exception  of  the  last,  Payr's  method  has 
the  same  drawbacks  and,  moreover,  it  requires  a  special  implement,  the  ring, 
which  may  not  be  at  hand,  and  may  cause  thrombosis  by  pressure  necrosis  of 
the  ring  on  the  vessel  wall.  Broad  marginal  confrontation,  whether  by  suture 
or  metal  flanges,  also  somewhat  reduces  the  vessel's  leng-th.     The  direct  mar- 


FiG.  39. — Jeger's  Tension 
Suture  Holder. 


^ 


J 


b <^..,^i,'.ai.i.-,A 


Fig.  40. — Dobrowolskaja's  Flap  Incision  for  Widening  Small  Vessels  at  the  Line  of  Union. 


ginal  approximation,  on  the  other  hand,  neither  shortens  the  artery  nor  appre- 
ciably narrows  its  lumen.  Moreover,  it  can  be  done  without  any  special  equip- 
ment other  than  well-lubricated  suture  material  and  needles  of  requisite  fine- 


OPEKATIOXS    rPOX    AETERIES  273 

uess.  But  above  all  in  its  favor  is  the  excellence  of  its  published  results,  as  ob- 
tained in  experimental  work.  It  requires,  perhaps,  a  higher  degree  of  dexterity 
to  accomplish  than  a  union  by  invagination,  or  with  metal  flanges;  but  this 
need  deter  no  one  who  is  willing  to  spend  some  time  in  practicing  its  technic. 
Matas  says:  ''The  Carrel  technique  has  become  the  method  of  election  at  the 
present  time." 

Jeger  calls  Carrel's  the  best  technic  for  the  surgeon  skilled  in  blood  ves- 
sel work,  but  points  out  that  it  is  difficult  and  takes  considerable  time  in  the 
impracticed  hand,  although  Carrel  can  do  a  circular  suture  in  five  minutes. 
Further  he  says  that  Payr's  method,  while  not  offering  the  same  safety  (as 
regards  thrombosis)  as  Carrel's,  is  far  simpler,  more  rapid,  and  is  especially 
applicable  in  accidents,  in  war  time,  etc.  This  method,  with  modifications  as 
practiced  by  him,  has  given  good  results. 

In  regard  to  the  restoration  of  vascular  channels  in  general,  Guthrie  believes 
it  is  safe  to  say  that,  when  patency  of  lumen  can  be  preserved,  it  is  better  to 
repair  the  defect  by  suturing  than  to  ligate  the  vessel.  He  adds  that  in  the 
event  of  much  vessel  wall  being  destroyed,  or  if  it  has  to  be  removed,  then 
preservation  becomes  doubtful ;  and  one  of  four  things  can  be  done : 

(1)  Ligate  on  both  sides  of  the  defect, 

(2)  Restore  defect  by  a  patch, 

(3)  Transverse  excision  with  circular  suture, 

(4)  Transverse  excision  with  transplant  by  circular  suture. 

The  first  is  safe  on  secondary  arteries,  like  ulnar;  less  so  on  intermediate 
arteries,  like  brachial;  unsafe  on  primary  arteries,  like  renal. 

The  second  is  more  complicated,  difficult  and  liable  to  thrombosis  than  cir- 
cular suture. 

The  third  is  preferable,  if  it  does  not  cause  too  much  tension. 

If  there  is  too  m.uch  tension,  use  the  fourth  procedure. 

With  asepsis  and  careful  suturing  an  arterial  anastomosis  involves  no 
gTeater  dangers  than  are  encountered  in  any  other  class  of  operations  upon 
important  anatomical  structures;  and  the  difficulties,  while  considerable,  are 
such  only  as  can  be  overcome  by  patience  and  perseverance.  The  invagination 
methods  would  probably  be  found  the  easiest  in  the  majority  of  hands;  but 
this  is  not  sufficient  to  prefer  them  over  the  direct  marginal  suture.  The  intro- 
duction of  the  least  infection  into  the  wound;  any  but  the  gentlest  handling 
of  the  vessels ;  carelessness  in  allowing  them  to  dry  out  or  to  be  invaded  by 
foreign  tissue,  or  tissue  juices;  failure  to  remove  blood  and  blood  clots;  these 
are  the  causes  that  may  act  to  invalidate  the  operator's  efforts  by  inducing 
thrombosis.  An  ill-placed,  insecurely  tied  suture,  or  too  great  tension  on  the 
sutures,  may  permit  of  secondary  hemorrhage,  though  this  is  rare;  and  a  cer- 
tain degTce  of  stenosis  may  be  produced  by  too  small  a  ring  or  by  a  continuous 
suture  too  tightly  drawn. 

Carrel  says  of  his  method :    ''If  the  technique  here  described  is  followed,  no 
complications  occur."     And  his  results  bear  out  this  bold  statement. 
19 


274  OPERATIOATS    UPOX    BLOOD    VESSELS 

Results  of  Circular  Suture  of  Arteries. — Buchanan  collected  from  the  liter- 
ature 29  cases  (besides  his  own)  np  to  jSTov.  1,  1911.  Erom  an  analysis  of 
these  cases  it  appears  that  the  mortality  was  6  2/3  per  cent. ;  and  complete 
recoveries  with  good  circulation  of  the  parts  83  1/3  per  cent. ;  while  the  partial 
recoveries,  in  which  gangrene  requiring  amputation  gave  incontrovertible  evi- 
dence of  failure  to  reestablish  a  normal  circulatory  condition,  were  10  per  cent. 

It  is  not  apparent  that  either  of  the  two  deaths  was  directly  attributable  to 
the  operation.  One  was  reported  as  due  to  delirium  tremens ;  and  the  other 
patient  was  said  to  be  moribund  from  hemorrhage  when  operated  upon.  A  bet- 
ter selection  of  cases  would  perhaps  have  resulted  in  lower  mortality. 

The  only  autopsy  reported  showed  "artery  pervious  (after  5  days)  with 
thrombus  in  part  of  its  lumen." 

ISTow,  as  to  the  recoveries,  it  is  reasonable  to  suppose,  if  the  pulse  below  the 
injury  has  been  feeble  or  imperceptible  before  operation  and  becomes  stronger 
soon  after  the  anastomosis  has  been  accomplished,  that  blood  is  reaching  the 
distal  portion  of  the  vessel  via  the  anastomosed  segment;  and,  if  the  pulse  re- 
mains strong  without  intermission,  it  is  fair  to  believe  that  the  patency  of  the 
lumen  has  been  maintained.  But  if  the  pulse  does  not  very  rapidly  return  after 
anastomosis,  or  if,  having  rapidly  returned,  it  later  disappears  or  becomes  very 
much  feebler,  it  would  appear  probable  that  the  lumen  of  the  vessel  has  been 
narrowed  or  obliterated  at  the  anastomotic  site,  and  that  collateral  circulation 
was  responsible  for  the  healthy  condition  of  the  part  distal  to  it.  l^aturally,  if 
gangTene  appears  in  the  part  distal  to  the  suture,  one  supposes  a  failure  due  to 
complete  or  nearly  complete  occlusion  of  the  vessel  operated  upon,  as  well, 
probably,  as  to  a  serious  amount  of  damage  in  the  collateral  vessels,  such  as  may 
have  occurred  in  crushing  injuries.  Arguing  on  this  basis,  it  is  not  clear  that 
more  than  11  of  the  above  reported  cases  were  successful  in  reestablishing  and 
maintaining  the  circulation  through  the  injured  segment,  since  in  only  11  is 
the  pulse  stated  to  have  returned  within  24  hours ;  and  Thoma  says  that  return 
of  pulse  (due  to  collateral  circulation)  below  the  ligated  main  trunk  of  a  ves- 
sel can  occur  as  early  as  24  hours  postoperative,  in  young  subjects,  and  pro- 
portionately later  in  older  persons.  This  would  be  36  2/3  per  cent,  of  operative 
successes  in  a  strict  sense ;  but,  since  there  were  over  80  per  cent,  of  recoveries 
with  good  circulation,  it  is  just  to  say  that  the  anastomosis  had  perhaps  served 
its  purpose  by  permitting  a  partial  but  sufficient  flow  of  blood  to  reach  the 
distal  parts  during  the  time  required  for  development  of  the  collateral 
supply. 

The  results  of  arterial  circular  suture  in  animals  are  more  brilliant.  An 
analysis  of  the  results  of  Borst  and  Enderlen,  Yamanouchi,  Ward,  Stich,  Glass- 
tein,  and  Carrel,  as  quoted  by  Jeger,  shows  71.2  per  cent,  successes  in  a  total 
of  148  cases  done  by  the  Carrel  method. 

Jeger  quotes  an  interesting  compilation  by  Sofoteroff  which  compares  the 
relative  percentage  of  successes  in  end-to-end  anastomosis  of  vessels  by  Mur- 
phy's, Payr's  and  Carrel's  methods : 


OPERATIONS    VFOls    ARTERIES  275 

90  cases  of  end-to-end  anastomosis,  Murphy  method,  15.5  per  cent. 
96     "         "  "  "  Payr  "  17.6     "       " 

352     "         "  "  "  Carrel  "         49.8     "       " 

Arteriovenous  Anastomosis 

Arteriovenous  anastomosis  is  the  procedure  of  forming  a  communication 
between  an  arterv  and  a  vein  in  such  manner  that  the  arterial  blood  is  admitted 
to  the  vein  for  the  purpose  of  displacing  its  contents  and  causing  reversal  of 
the  circulation. 

Thus  far,  this  procedure  has  been  used  onl}^  in  cases  of  expected  or  actual 
gangrene  of  the  limbs  due  to  (1)  Raynaud's  disease;  (2)  obstruction  of  the 
main  arterv  from  endarteritis,  thrombo-arteritis,  embolus,  or  trauma.  The 
instruments  required  are  the  same  as  for  suture  of  arteries.  The  anastomosis 
may  be  made  end-to-end,  side-to-side,  or  end-to-sidc. 

End-to-End  Arteriovenous  Anastomosis. — MUEPHY  'S  METHOD. — The  steps  in 
the  invagination  method  are  as  follows:  (1)  Expose  artery  and  vein;  isolate 
both  and  provide  temporary  hemostasis.  (2)  Divide  both  vessels,  the  vein 
Yo  inch  to  %  inch  higher  than  the  artery,  if  possible.  (3)  Ligate  permanently 
the  distal  stump  of  the  artery  and  proximal  stump  of  vein.  (4)  Apply  forceps 
(Fig.  18)  around  distal  segment  of  vein  near  its  end ;  evert  and  roll  back  open 
end  of  vein  like  a  cuff  upon  it.  (5)  Suture  cut  end  of  artery  to  reflected  border 
of  venous  cuff  by  interrupted  stitches.  (6)  Pull  reflected  vein  cuff  forward 
over  line  of  suture  and  stitch  its  cut  edge  to  outer  surface  of  artery.  (7)  Re- 
move forceps  and  close  wound  without  drainage.  Murphy  now  uses  this  method 
in  arterial  suture  also. 

CAEEEL'S  METHOD. — The  procedure  in  end-to-end  suture  of  artery  to 
vein  is  the  same  as  in  his  method  of  uniting  artery  to  artery  except  that  the  cut 
edge  of  the  vein  is  somewhat  everted,  so 

that  its  endothelial  surface  lies  against        ■Wlflllllliiil'tlfffff'MW^i.  ^ 
the  cut  edffe  of  the  artery   (Fig.  41).  wimi^^-^^^^^''^'^^'^—^7^ 

As  the  vein  is  usually  larger  than  the        .,_,  /flMSi'F'''''il'''7/ll''''v( 

artery,   sufficient  pull  is   exerted  upon       l[(|(ij(f('('(i'([(|'|'(](|]]])4 
the  three  traction  sutures  to  stretch  the      JImMmS^PW""^'"'"^^^ 
artery  nearer  to  the  size  of  the  vein  and      -n      . ,     t.  .  . 

•^      _  _  Fig.  41. — End-to-end  Arteriovenous  Anas- 

each     stitch     of  the     continuous     suture       tomosis:  Approximation  of  the  Ends  (Carrel). 

is  made  larger  on  the  vein  and  at   a 

slightly  gTeater  distance  from  its  cut  edge  than  the  corresponding  stitch  on  the 
artery.  This  has  the  effect  of  slightly  puckering  the  vein  and  thus  reduces  its 
lumen  to  correspond  with  that  of  the  artery.     (Fig.  42.) 

End-to-Side  Arteriovenous  Anastomosis. — End-to-side  (Carrel  and  Guthrie) 
anastomosis  (for  arterial  or  arteriovenous  anastomosis)  may  be  made  by: 

(1)  Preparing  the  proximal  stump  of  the  artery  as  for  an  end-to-end  anas- 
tomosis and  ligating  the  distal  end.  (2)  Temporary  hemostasis  is  then  applied 
to  the  corresponding  segment  of  the  vein,  after  being  isolated,  and  an  elliptical 


276 


OPEEATIOIvTS    UPOIST    BLOOD    VESSELS 


opening  made  into  it  a  trifle  larger  than  the  size  of  the  arterial  lumen  by  lift- 
ing up  a  bit  of  its  wall  in  forceps  and  cutting  it  out  with  sharp  scissors.  (Eig. 
43.)     (3)  The  blood  is  then  pressed  out  and  the  edges  of  the  opening  vaselined 


Fig.  42. — End-to-end  Arteriovenous  Anas- 
tomosis: Application  of  Continuous 
Suture   (Carrel) . 


'iiiiimffff///!{/ii//f(!(t^/'ii/ii/i^'^'' ' 


Fig.    44. — End-to-side   Anastomosis:    Fixa- 
tion Sutures  Introduced  (Carrel). 


■T(^^\^!f\^W^  .pWWWfTl 


*W»' 


Fig.    43. — End-to-side    Anastomosis:     Oval 
Opening  into  Vein  (Carrel). 


Fig.    45. — End-to-side    Anastomosis:    Com- 
pleted (Carrel). 


and  three  or  four  traction  sutures  tied  on  the  outside  of  the  vessels  are  made 
to  approximate  the  end  of  the  artery  to  the  side  of  the  vein  (Fig.  44).  (4) 
Traction  on  these  sutures  triangulates  or  squares  the  junction  of  the  vessels 
and  a  continuous  suture  is  made  to  unite  their  edges  (Fig.  45).  (5)  The  vein 
is  permanently  ligated  above  the  point  of  anastomosis,  and  the 
temporary  hemostats  on  vein  and  artery  removed. 

They  also  describe  a  "patching"  method:  If  one  of  the 
vessels  is  too  small  to  handle  conveniently,  it  may  be  excised 
with  a  part  of  the  wall  of  its  parent  trunk  (Fig.  46)  and  the 
latter  attached  to  the  oval  opening  in  the  other  vessel  (Fig. 
47)  and  united  with  it  by  continuous  suture  (Fig.  48). 


D 


Fig.  46.  —  Car- 
rel's Patch- 
ing Method  : 
Small  Vessel 
Excised  with 
Part  op  Large 
(Carrel). 


WIETING'S  METHOD.^ — Wieting's    method    of    end-to-side 


anastomosis,  practically  similar  to  Van  Hook's  terminolateral 
ureteroureteral  anastomosis,  is  open  to  the  theoretical  objec- 
tion, at  least,  of  leaving  a  raw  edge  in  contact  with  the  blood 
stream.  The  proximal  cut  end  of  the  artery  is  introduced 
through  a  slit  in  the  side  of  the  vein  and  anchored  there  by  one  retaining  suture 
that  is  tied  on  the  outside  of  the  vein,  and  a  continuous  suture  unites  the  cut 
edees  of  the  vein  to  the  outer  surface  of  the  arterv.  The  vein  is  then  lie-ated 
closely  proximal  to  the  anastomosis.. 


OPERATIONS  UPON  ARTERIES 


277 


JEGER'S  METHOD. — Jeger  has  devised  a  method  for  end-to-side  anas- 
tomosis far  superior  to  Wieting's.  It  is  described  under  operations  on  veins, 
but  it  might  be  applied  to  arteriovenous 
anastomosis. 

Side-to-Side  Arteriovenous  Anastomo- 
sis  CAEREL'S    METHOD. —  (1)      After 

proper  exposure,  isolation  and  hemo- 
stasis,  both  vessels  are  opened  longi- 
tudinally, at  corresponding  points,  for 
a  distance  a  little  greater  than  the  di- 
ameter of  the  artery,  by  incision  with  a 
scalpel  or  excision  of  an  elliptical  flap 
with  scissors,  and  the  adventiti  a 
trimmed  away.      (2)    Traction  sutures 

are  then  placed,  uniting  the  distal  and  proximal  ends  of  these  openings  (or 
points  close  to  them  on  the  adjacent  cut  margins)  and  tied  on  the  outside  of 


Fig.  47. — Carrel's  Patching  Method:  Stay 
Sutures  Inserted. 


Fig.  48. — Carrel's  Patching 
Method  :  Suture  Com- 
pleted. 


Fig.  49. — Side-to-side  Anas- 
tomosis: End  Tension  Su- 
tures Tied,  Adjacent 
Margins  United  by  Con- 
tinuous Suture,  Ante- 
rior Tension  Suture  In- 
serted but  not  Tied 
(Carrel). 


Fig.  50.  —  Side-to-side 
Anastomosis:  Ante- 
rior Tension  Suture 
Tied;  Continuous  Su- 
ture Nearing  Com- 
pletion (Carrel). 


the  vessels.     (3)  While  traction  is  made  on  these  sutures,  the  needle  on  the  long 
end  of  the  distal  one  is  made  to  penetrate  the  wall  of  the  vessel  from  without 

iuM^ard  and  a  continuous  suture  is 
carried  by  means  of  it  along  the 
adjacent  margins  of  the  openings, 
on  their  endothelial  surface,  and 
after  piercing  the  wall  at  the  prox- 
imal end  of  the  opening  is  tied, 
on  the  outside  of  the  vessels,  to 
the  proximal  traction  suture  (Fig. 
49).  (4)  A  third,  or  anterior, 
traction  suture  is  then  made  to 
approximate  the  distal  margins 
of  the  two  openings  in.  the  ves- 
sels at  their  middle  and  tied  on  their  outer  surface.  (5)  Traction  on  this,  and 
upon  the  posterior  proximal  and  distal  traction  sutures,  angulates  and  approxi- 


FiG.    51. — Side-to-side    Anastomosis    Completed, 
Showing  Extra  End  Sutures  of  Guthrie. 


278 


OPEKATIO^'S    UPOX    BLOOD    VESSELS 


mates  tlie  anterior  margins  of  tlie  wounds,  whicli  are  then  united  by  a  continua- 
tion of  the  suture,  working  upon  the  adventitial  surface  of  the  vessels,  which  has 

already  been  used  to  unite  the  posterior  (or 
adjacent)  margins  of  the  vessel  openings. 
This  is  tied,  at  its  completion,  to  the  distal 
traction  suture  (Fig.  50). 

GUTHEIE 'S  METHOD.  —  Guthrie's 
method  dilfers  from  Carrel's  in  the  follow- 
ing respects : 

Guthrie  makes  the  openings,  in  width, 
about  y^  and,  in  length,  about  1%  the 
diameter  of  the  vessel,  if  the  entire  circula- 
tion of  one  vessel  is  to  be  diverted  through 
the  anastomosis.  He  places  a  temporary 
posterior  traction  loop  midway  between  the 
proximal  and  distal  traction  sutures  to  aid 
in  approximating  the  adjacent  margins 
while  they  are  being  united  with  the  con- 
tinuous suture.  This  is  placed  on  the  in- 
ternal surface,  is  not  tied,  and  is  cut  and 
withdrawn  before  the  anterior  traction  su- 
ture is  introduced.  He. ties  the  continuous 
suture  with  the  anterior  traction  suture  as 
well  as  with  the  proximal  and  distal.  If 
much  strain  is  likely  to  be  exerted  upon  the 
suture  line,  he  reinforces  it,  at  proximal  and  distal  ends  (Fig.  51),  by  a  some- 
what coarser  sinaie  suture. 


Fig.  52. — Bernheim's  Anastomosis: 
Dividing  Vessel,  for  Lateral 
Ajstastomosis  and  Resultant 
Gaping  of  Incision. 


Fig.  53. — Bernheim's  Anasto- 
mosis: Starting  the  Suture. 
The  knot  is  tied  on  the  outside 
of  the  vessels. 


Fig.  54. — Bernheim's  Anas- 
tomosis: Posterior  Row 
OF  Sutures  Being  Placed. 


LESPINASSE  AND  EISEXSTAEDT  METHOD. — They  have  used  oval  mag- 
nesium plates,  similar  to  those  used  for  end-to-end  anastomosis,  but  the  method 
is  less  promising  than  that  by  simple  suture. 


OPERATIOJsTS    UPOiT    ARTERIES 


279 


BEENHEIM  AND  STONE  METHOD. — (1)    After  dissection  and  clamping  of 
the  vessels  with  bull-dogs  or  Crile  clamps   (rubber-shod),   "a  sharp  cataract 


Fig.    55. — Bebnheim's    Anastomosis:    Posterior   Row  of  Sutures   Completed,  Anterior  Row 

Being  Placed. 


knife,  held  transverse  to  the  long  axis  of  the  vessel,  is  plunged  through  the 
arterj  in  a  direction  oblique  to  the  horizontal  plane  in  which  the  vessel  lies, 
so  as  to  form  a  sector  of  the  lumen  with  its  arc  equal 
to  about  Yg  of  the  circumference.  The  knife  is 
thrust  in  with  its  cutting  edge  up  and  toward  the 
adjacent  vein.  The  overlying  %  of  the  artery  is 
then  divided."  (Fig.  52.)  (2)  Wash  out  all  blood 
with  saline  and  moisten  lumen  and  other  surfaces 
with  liquid  vaselin.  (3)  Protect  the  artery  with 
vaselin-soaked  gauze  and  make  a  similar  incision  in 
vein  so  that  it  looks  toward  the  artery.  (4)  The 
suture  is  then  (Fig.  53)  started  at  the  lower 
end  of  the  two  incisions,  tied  on  the  outside  of 
the  vessels,  and  made  continuous  (Fig.  54)  back 
to  the  starting  point,  where  it  finishes  by  tying 
with  the  first  end  (Fig.  55).  (5)  Ligate  vein 
on  proximal  side  and  loosen  distal  venous  clamps 
(Fig.  56).  (G)  Loosen  distal  and  then  prox- 
imal artery  clamps.  (7)  Reinforce,  if  necessary, 
for  leakage. 

Bernheim  thinks  lateral  arteriovenous  anasto- 
mosis better  than  end-to-end  because  it  allows  some 
blood  to  continue  down  the  artery  and  does  not  en- 
tirely cut  off  the  circulation  if  the  vein  becomes 
occluded  by  thrombosis. 

Choice  of  Methods. — If  one  judges  by  results, 
the  choice  of  methods  is  difficult.     In  the  series  of 

cases  collected  by  ITalstead  and  Vaughan  the  technic  used  was  specifically 
mentioned  in  17  cases: 


Fig.  56. — Bernheim's  Anas- 
tomosis :  Suture  Com- 
pleted, Tied  and  Cut. 
Clamps  removed.  Proxi- 
mal ligation  of  vein. 


280 


OPEEATIONS    UPON    BLOOD    VESSELS 


No.  OF 

Cases 

Deaths 

Pabtial 
Recoveby 

Complete 
Recovery 

6 
6 
5 

Wieting :  lateral  implantation  artery  into  vein. 
Carrel :  end-to-end  suture  of  artery  into  vein. 
Invagination:  end-to-end,  of  artery  into  vein. 

3 
3 
3 

2 
2 

2 

1 
1 

In  Bernheim's  collection  of  cases  there  were  46  in  which  the  technic  used 
was  specified: 


No.  op 

Cases 


Successful 


23 
12 

9 
2 


Carrel:  end-to-end  sutures. 

Lateral  anastomosis 

Wieting's  intubation 

End-to-end  invagination . . . 


34.78% 
33.33% 
22.22% 
50.00% 


So  far  Bernheim  seems  to  have  had  the  best  results  of  any  one  operator, 
but  his  method  has  not  been  used  by  others  sufficiently  to  judge  its  efficiency  in 
general  hands. 

This  is  an  operation  by  no  means  devoid  of  danger  in  the  class  of  cases  for 
which  it  has  been  employed.  Halstead  and  Vaughan  have  collected  41  cases, 
with  42  operations,  up  to  January,  1911,  and  of  these  21  died,  11  after  the 
primary  operation,  9  after  a  secondary  amputation,  and  1  after  opening  a 
secondary  abscess.  Three  of  these  21  deaths  were  apparently  directly  attrib- 
utable to  the  anastomosis  operation. 

The  same  causes  of  failure  act  here  as  in  arterial  anastomosis,  thrombosis 
being  by  far  the  commonest.  Hesse  performed  thrombectomy  for  a  thrombus 
that  formed  while  he  was  doing  an  arteriovenous  anastomosis  between  the 
femoral  artery  and  long  saphenous  vein.  The  thrombus  at  once  reformed, 
however,  and  he  had  to  make  his  anastomosis  end-to-end  with  the  femoral  vein. 
In  the  series  of  41  cases  reported  by  Halstead  and  Vaughan  there  were  28  in 
which  pathological  findings  at  amputation  or  autopsy  were  included.  Among 
these  were : 

Thrombus  in  all  vessels 5  cases 

Thrombus  in  femoral  artery  above  and  popliteal  artery  be- 
low       5  cases 

Thrombus  in  femoral  vein  alone  below 5  cases 

Short  circuiting  by  collaterals  of  vein. 1  case 

Occlusion  of  central  end  of  artery 2  cases 


This  shows  thrombosis  to  be  a  fertile  cause  of  failure. 


OPERATION'S    UPON^    ARTERIES  281 

Results. — In  many  cases  the  immediate  result  is  good,  but,  more  ana  more, 
the  men  who  have  had  experience  with  this  operation  are  coming  to  feel  that 
little  permanent  benefit  can  be  expected  from  it. 

Oppel  says  that  arteriovenous  anastomosis  is  successful  only  in  cases  of 
slowly  progressing  ischemic  gangrene,  not  complicated  by  thrombophlebitis  or 
phlegmon ;  and  he  believes  that  the  improvement  is  due  to  delayed  venous  re- 
turn and  suggests  ligation  of  popliteal  vein  as  a  palliative  measure  (instead  of 
arteriovenous  anastomosis).  Hesse,  also,  believes  that  Wieting's  operation  is 
inefficient  and  that  the  improvement  following  it  is  due  not  to  reestablishment 
of  circulation,  but  to  stasis,  which  follows  stoppage  of  venous  return.  After 
11/4  months  improvement,  his  patient  came  to  amputation  when  it  was  noted 
that  there  was  no  pulsation  in  the  femoral  vein  and  that  venous  appearing  blood 
flowed  from  the  veins. 

Perimow  advises  anastomosis  of  the  artery  with  superficial  veins  because  the 
latter  have  few  or  no  valves,  on  the  ground  that  the  valves  prevent  reversal  of 
circulation  in  arteriovenous  anastomosis.     This  appears  fallacious. 

Bernheim  says  that  he  has  successfully  reversed  the  circulation  in  all  four 
limbs  of  a  young  woman,  as  evidenced  by  cessation  of  gangrene  of  toes  and 
fingers  and  presence  of  a  palpable  thrill  below  anastomosis ;  a  bruit  audible  to 
the  popliteal  space,  in  legs,  and  to  wrist,  in  arms ;  and  pulsation  of  veins,  felt, 
in  lower,  and  seen  in  upper,  extremities. 

Halsted  and  Vaughan,  of  Chicago,  in  a  splendid  paper  on  arteriovenous 
anastomosis,  have  collected  42  operations,  11  for  "threatened,"  and  31  for 
actual  gangTene.  They  state  that  local  changes,  indicating  an  immediate  im- 
provement, were  noted  in  23  cases,  in  order  of  frequency:  (1)  Increased 
warmth  in  the  affected  parts;  (2)  improvement  in  color  (often  the  only  sign 
noted);  (3)  relief  from  pain;  (1)  improvement  in  sensation;  (5)  filling  of 
superficial  veins ;  ( 6 )  pulsation  in  veins  of  extremities  below  site  of  anastomosis 
(14  cases)  ;  (7)  return  of  the  part  threatened  by  gangrene  or  the  actual  seat 
of  gangrene,  to  the  normal. 

The  case  of  Ballance  is  said  to  be  the  only  one  found  where  circulation  was 
so  far  improved  by  anastomosis  as  to  control  an  actually  existing  gangrene  and 
bring  about  restoration  of  the  part  not  actually  gangrenous.  In  Wieting's  casQ 
there  was  no  sigTi  of  return  of  "threatened"  gangrene  for  at  least  two  months. 
In  all  the  remainder  of  the  cases  the  favorable  sieiis  were  of  short  duration. 


"fe^ 


There  were  21  deaths :  - 


after  primary  operations,  11 
after  secondary  amputation,  9 
after  opening  abscess,  1 


a  mortality  of 
50  per  cent. 


Death  was  directly  traceable  to  arteriovenous  anastomosis  operation  in  3 
cases, — 7.1  per  cent. 

Their  conclusions  serve  very  well  to  exhibit  the  dark  side  of  the  picture. 


282  OPERATIONS    UPON    BLOOD    VESSELS 

"There  is  experimental  evidence  to  show  that  in  animals  the  circulation  through 
the  large  veins  of  the  extremities  may  be  reversed,  and  that  it  is  possible  for  the 
normal  pressure  in  the  arteries  to  overcome  the  resistance  of  the  valves  in  the  veins. 

"Experimental  and  clinical  evidence  show  that  the  anastomotic  opening  is  not 
permanent,  but  that  gradual  obliteration  by  intimal  overgrowth  takes  place  in  event 
of  the  failure  of  early  occlusion  by  a  thrombus. 

"There  is  not  sufficient  clinical  evidence  in  the  reported  cases  to  show  that  the 
pressure  of  blood  in  the  arteries  in  the  cases  operated  upon  was  sufficient  to  force  the 
valves  in  the  veins. 

"It  is  also  shown  by  the  cases  reported  that  early  occlusion  of  the  vessels  about 
the  anastomotic  opening  by  a  thrombus  was  the  rule,  and  in  many  the  opening  never 
at  any  time  functionated. 

"In  event  of  the  arterial  blood  forcing  the  valves  in  close  proximity  to  the  anas- 
tomotic opening,  it  returns  through  the  larger  communicating  veins  in  many,  if  not 
most,  instances,  and  does  not  transverse  the  capillaries. 

"A  study  of  traumatic  arteriovenous  aneurysm  shows  that  with  a  normal  arterial 
pressure  it  requires  weeks  or  months  for  the  valves  in  the  communicating  vein  to  be 
overcome,  as  is  evidenced  by  the  gradual  development  of  varicosities  and  the  long, 
delayed  pulsation  in  veins  remote  from  the  seat  of  the  aneurysm.  Under  these  condi- 
tions, the  arterial  blood  supply  is  maintained  partly  through  the  usual  collateral  chan- 
nels which  are  unobstructed.  In  cases  of  gangrene  from  obliterating  disease  of  the 
arteries,  the  collateral  vessels  are  already  occluded.  In  such  a  case,  immediate  re- 
versal of  the  circulation  is  imperative.  This  cannot  be  accomplished  at  present:  (a) 
because  of  the  obstruction  offered  by  the  valves ;  (b)  because  in  many  cases  the  circu- 
lating blood  must  also  overcome  the  resistance  offered  by  a  thrombosed  vein;  (c)  be- 
cause the  blood  returns  through  the  nearest  communicating  vein  and  does  not  reach 
the  peripheral  capillaries. 

"Our  final  conclusion  is  that  there  is  but  one  indication  for  the  application  of 
arteriovenous  anastomosis  in  surgery;  i.  e.,  in  traumatic  destruction  of  a  principal 
artery,  where  end-to-end  union  of  the  torn  vessel  is  impossible.  In  such  a  case,  arterio- 
venous anastomosis  might  be  attempted,  and  through  it  we  might  maintain  a  sufficient 
blood  supply  to  preserve  the  integrity  of  the  limb  until  an  adequate  collateral  circula- 
tion was  established." 

This  is  a  gloomy  picture,  indeed,  and  Coenen  adds  nothing  cheerful  to  it ; 
but  all  of  the  cases  chosen  for  this  procedure  were  bad  surgical  risks,  and  none 
of  the  operators  had  previously  done  more  than  4  similar  operations. 

A  criticism  of  their  mistakes  and  a  brighter  view  of  the  possibilities  of 
the  operation  are  given  by  Bernheim.  He  says  "animal  experimentation,  and 
lots  of  it,  is  an  absolute  necessity  to  the  surgeon  who  wishes  to  do  clinical  work 
in  the  field  of  vascular  surgery."  In  a  paper  on  arteriovenous  anastomosis 
he  collected  52  cases  from  the  literature,  up  to  1912,  not  including  15  of  the 
cases  collected  by  Halstead  and  Vaughan,  but  including  25  cases  not  men- 
tioned in  their  table.  Of  these  52  cases,  he  calls  15  successful.  Of  these 
"successes,"  4  required  amputation  within  4  months.  Another  "success"  died 
of  erysipelas  on  the  fifteenth  day  after  operation.  Another  had  been  followed 
only  2  months.  Another  had  pulsation  in  vein  noted  only  for  8  days.  In 
another  there  was  only  improvement  in  the  pain.  Halstead  and  Vaughan  re- 
port two  complete  recoveries  in  their  sel'ies  of  42  collected  cases,  or  5  per  cent., 


OPERATIONS    UPON    ARTERIES  283 

and  6  partial  recoveries,  or  14  per  cent.  While  Bernheim  reports  15  "suc- 
cesses," or  2S  per  cent. 

It  would  seem  from  a  review  of  these  statistics  that  success  means  one 
thing  to  one  operator,  another  to  another.  One  is  satisfied  if  the  vein  pulsates 
for  a  few  moments,  while  another  demands  that  there  be  arrest  of  the  actual 
gangrene  present,  or  a  disappearance  of  signs  pointing  to  the  onset  of  an  ex- 
pected gangTene,  with  return  of  the  part  to  normal.  Between  these  extremes 
lie  many  possible  chances  for  controversy  that  can  never  be  settled  until  sur- 
geons agree  upon  a  definition  of  success  in  this  procedure. 

A  middle  ground  seems  safest  as  pointed  out  by  Lilienthal,  who  makes 
no  extravagant  claims.  He  believes  that  there  is  a  field  for  the  operation  in  a 
certain  few  selected  cases  and  that  its  attempt  is  justified  in  a  considerable 
number  as  a  palliative  measure  to  delay  amputation  or  make  possible  amputa- 
tion at  a  lower  level  than  could  otherwise  be  done. 

In  a  personal  communication  Lilienthal  states  that  he  has  recently  done 
4  cases  of  ligation  of  femoral  vein  (as  suggested  by  Coenen,  Hesse,  and 
Oppel)  for  expected  gangi-ene  in  thrombo-angeitis  obliterans,  with  absolute 
relief  of  pain  in  3  cases.  He  says  there  is  no  swelling  of  the  leg  as  a  result 
of  the  ligation,  but  that,  on  the  contrary,  what  swelling  may  be  present  is  re- 
lieved. 

Aetekial  Section 

Arterial  section  is  the  procedure  of  incising  an  artery  for  the  removal  of 
a  blood  clot  and  restoring  the  integTity  of  its  wall  by  suture. 

Binnie,  pointing  out  the  difference  between  an  embolus  lodged  in  an  other- 
wise more  or  less  healthy  artery  and  a  thrombus  formed  in  a  segTuent  of 
injured  or  diseased  vessel,  wisely  says  in  regard  to  the  latter,  "removal  of 
the  blood  clot  alone  is  valueless,  as  another  clot  will  form  immediately."  But, 
"when  the  closure  of  the  artery  is  due  to  the  lodgment  of  an  embolus,  it  is 
logical  to  open  the  vessel  by  a  longitudinal  incision  after  providing  for  tem- 
porary hemostasis,  extract  the  clot,  wash  the  interior  of  the  vessel  segregated 
by  the  hemostatic  tapes  or  slips  with  salt  solution,  smear  it  with  sterile  vase- 
lin  and  close  the  wound  with  sutures." 

For  arterial  section  on  vessels  of  the  extremities  the  same  instruments  are 
used  as  in  arterial  suture,  including  a  sharp,  small,  thin-bladed  scalpel. 

Technic  of  Operation. — The  operation  is  performed  as  follows:  (1)  The 
artery  is  cut  down  upon  in  the  location  of  the  embolus  and  palpated  care- 
fully. If  it  is  pulseless  and  feels  solid  it  is  carefully  and  gently  isolated 
from  its  sheath,  temporary  hemostasis  applied,  if  necessary,  a  longitudinal 
incision  made  through  its  superficial  surface  and  the  embolus  extracted  by 
finger,  or  forceps  (which  must  not  touch  the  intima),  or  by  means  of  milk- 
ing the  vessel  toward  the  wound.  (2)  When  blood  flows  freely  from  peripheral 
and  central  ends,  temporary  hemostasis  is  applied  above  and  below  the  seg- 
ment that  contained  the  clot,   the  lumen  washed  out   with  warm  saline  or 


284  OPERATIONS    UPOI^    BLOOD    VESSELS 

Ringer's  solution,  and  all  the  blood  washed  and  sponged  carefully  out  of  the 
surrounding  wound.  (3)  The  interior  and  cut  edges  of  the  vessel  are  then 
moistened  with  liquid  albolene  and  the  incision  closed  in  the  same  manner 
as  described  for  lateral  suture  of  arteries.  (4)  The  wound  is  then  closed  with- 
out drainage.  (5)  If  the  circulation  has  been  restored  by  the  operation  the 
pulse  should  be  felt  at  once  in  the  artery  or  its  branches  below  the  point  of 
incision.  (6)  In  case  another  embolus  lodges,  or  a  thrombus  forms  at  the  orig- 
inal site,  it  is  perhaps  better  to  perform  arteriovenous  anastomosis  at  a  point 
below  the  embolus,  if  this  is  possible,  than  to  repeat  embolectomy. 

The  dangers  and  difficulties  are  no  greater  than  in  lateral  arterial  suture, 
but  the  operation  is  very  likely  to  be  unsuccessful  on  account  of  thrombus 
formation  at  the  site  of  the  embolus  and  the  published  results  are  therefore 
bad. 

Results. — Matas  mentions  Y  cases  that  were  reported  previous  to  1908.  In 
four  of  these  the  embolism  occurred  in  the  lower  extremity.  In  all  7  another 
clot  promptly  re-formed  after  removal.  Later  amputation  had  to  be  per- 
formed in  all  the  cases. 

The  pulmonary  artery  has  been  sectioned  for  embolus  12  times  (up  to 
February,  1913)  at  Trendelenburg's  Clinic.  There  were  no  permanent  re- 
coveries, but  one  patient  lived  5  days  after  operation,  dying  of  pneumonia. 
For  such  operations  upon  the  pulmonary  artery  Trendelenburg  has  devised 
special  instruments  which  are  described  with  this  operation. 

I  have  been  able  to  find  but  few  recent  cases  of  arterial  section  for  embolus. 
One  is  reported  by  Key.  Twenty  days  after  an  attack  diagnosed  as  probable 
embolism  or  thrombosis  of  the  mesenteric  artery,  with  recovery  after  palliative 
treatment,  a  man  43  years  old,  with  mitral  stenosis  of  several  years'  duration, 
was  suddenly  seized  with  severe  pain  in  left  popliteal  space,  coldness  and  loss 
of  sensation  in  leg.  Seven  hours  after  onset  operation  was  performed.  In- 
cisions over  dorsum  of  foot  and  in  popliteal  space  revealed  empty  vessels.  The 
common,  deep  and  superficial  femoral  arteries  were  then  exposed  and  resist- 
ance was  felt  in  the  common  femoral  from  its  bifurcation  2.5  cm,  upward, 
which  proved  on  incision  of  the  artery  to  be  an  embolus  completely  filling  its 
lumen.  Clamps  were  placed  upon  the  common  and  deep  femoral  arteries  and 
the  embolus  removed  with  a  consequent  hemorrhage  from  collateral  vessels 
through  external  pudic  and  from  the  tissue  incisions  which  had  not  bled 
before.  The  limb  was  elevated  after  operation  and  during  convalescence 
there  were  noted  temporary  paralysis  of  the  femoral  muscles  and  thrombosis 
of  the  external  peroneal  veins,  with  stricture  of  the  gastrocnemius  muscle, 
probably  caused  by  slight  ischemic  contracture.  He  found  three  cases  of 
operation  for  embolus  in  the  literature,  one  success  and  two  failures.  He 
does  not  state  whether  the  pulse  became  or  remained  palpable  in  the  post- 
tibial  artery,  but  his  case  seems  to  have  been  successful  in  avoiding 
gangrene. 

Murad  Bey  did  an  arterial  section  for  embolus  of  left  brachial  artery, 


OPERATIONS    UPOIsT    VEITs^S 


285 


removed  the  clot  and  did  a  side-to-side  anastomosis  of  artery  and  vein,  central 
to  the  point  of  embolism.     A  new  thrombus  rapidly  formed. 

Mosuy  and  Dumont  were  able  to  remove  an  embolus  from  the  left  femoral 
artery  6  hours  after  its  lodgment,  through  a  1  cm.  incision  in  the  vessel.  The 
circulation  returned  and  continued. 

Lejars  removed  a  soft,  dark  thrombus  from  the  femoral  artery  after  gan- 
grene had  set  .in  following  thrombosis.  The  gangrene,  however,  was  not 
stopped. 

Trendelenburg  suggests  the  intravenous  injection  of  hirudin  to  prevent 
the  re-formation  of  thrombi  in  the  vessels.  Jeger  says  Bodong  and  Jacobi 
have  shown  that  in  animals  the  injection  of  considerable  amounts  of  hirudin 
gave  rise  to  no  noticeable  interference  with  respiration,  circulation  or  general 
condition,  and  that  the  injection  in  the  proportion  of  approximately  1  mg. 
hirudin  to  5  c.  c.  blood  delayed  clotting  for  4V>  hours. 

Transplantation  of  Arteries 

So  far,  for  the  reason  that  venous  transplants  are  satisfactory  in  function- 
ing and  require  no  serious  circulatory  disturbance  to  procure,  transplanta- 
tion of  arteries  is  not  at  present  being  done  in  human  patients.  In  animal 
work,  however,  the  following  results  are  encouraging. 


Stich 

Yamanouchi . 


Abtekial  Transplants 


2  autoplastic . . 
8  autoplastic . . 

5  homoplastic  . 
15  homoplastic  . 

5  homoplastic  . 

6  heteroplastic . 

7  heteroplastic . 
1  heteroplastic. 


Successes 


Stich 

Borst  and  Enderlen. 
Yamanouchi 


Yamanouchi . 

Stich 

Ward 


II.     OPERATIONS  UPON  VEINS 

ANATOMICAL     CONSIDERATIONS 

In  planning  or  undertaking  any  operative  procedure  upon  veins  it  must  bo 
remembered  that  we  are  dealing  with  collapsible  tubes,  generally  larger  in  size 
than  the  arteries  they  accompany,  with  much  thinner  walls,  and  with  lumina 
larger  in  proportion  and  gTiarded  at  intervals  by  valves ;  nor  should  it  be  for- 


286  OPEEATIOXS    UPOX    BLOOD    VESSELS 

gotten  that,  in  superficial  veins,  the  anastomosing  plexus  is  larger  and  denser 
than  in  arterial  vessels.  Moreover,  it  should  be  understood  that,  due  to  the 
very  different  internal  pressures  under  which  they  exist  in  the  living  organ- 
isms, veins  are  normally  not  distended  ani^-where  near  to  their  elastic  limit, 
while  arteries  frequently  are  so.  Besides  this,  their  walls,  although  primarily 
divisible  into  the  same  number  of  layers  as  those  of  arteries,  contain  much  less 
muscular  and  comparatively  far  more  elastic  and  fibrous  tissue.  Directly  de- 
pendent upon  these  structural  and  functional  differences  we  find  that  a  vein, 
emptied  of  blood,  collapses  and  its  lumen  becomes  obliterated ;  that  it  can  be 
stretched,  transversely  and  longitudinally,  to  a  comparatively  greater  degree 
than  an  artery;  that,  when  its  wall  is  partially  divided  by  a  transverse  (or 
more  especially  by  a  longitudinal)  wound,  the  edges  of  this  tend  to  fall  to- 
gether or,  at  any  rate,  gape  nmch  less  than  in  a  similar  arterial  injury;  and 
that,  when  transversely  divided  completely,  their  stumps  do  not  retract  nearly 
to  the  extent  of  those  in  a  divided  artery,  nor  does  the  periphery  of  the  vessel 
contract,  nor  does  its  hmien  remain  patent. 

OPERATIONS  TO  CHECK  BLEEDING 

Posture. — Elevation  of  the  part  above  the  level  of  the  rest  of  the  body  will, 
by  facilitating  venous  return,  help  to  check  oozing. 

Bandages  and  Compresses. — Bandages  and  compresses  applied  closely  to 
the  bleeding  point  will  readily  check  venous  bleeding  by  pressure  obliteration 
of  the  lumen. 

Gauze  Packing". — Gauze  packing  inserted  fairly  tightly  into  a  deep  wound 
will  control  venous  bleeding  in  most  cases  by  partial  obliteration  of  the  lumen 
and  mechanically  favoring  clotting. 

Digital  Pressure.- — Digital  pressure  may  be  used  in  the  same  manner  as  to 
control  arterial  bleeding,  except  that  it  must  be  applied  directly  over  the 
bleeding  point  or  distal  to  it. 

Torsion,  Forcipressure,  Terminal  Ligation  and  Ligation  en  Masse, — These 
methods  of  treatment  are  used  in  the  same  manner  as  for  arterial  bleeding. 

Actual  Cautery. — The  actual  cautery  at  a  red  heat  is  useful,  at  times, 
where  ligation  is  difficult  on  account  of  multiple  bleeding  points. 

OPERATIONS     TO     RESTORE     OR     REESTABLISH     THE     CIRCTJLATION 

Lateral  Ligatiox 

Lateral  ligation  is  the  lateral  application  of  a  ligature  to  close  a  wound  in 
the  wall  of  a  vein.  It  is  permissible  only  in  small  wounds  of  large  veins  where 
the  resulting  plication  of  the  wall  will  not  considerably  encroach  upon  the  size 
of  the  lumen. 

The  margins  of  the  wound,  are  carefully  grasped  in  a  hemostat  and  drawn 


OPERATIONS    UPON    VEINS  287 

gently  in  a  lateral  direction  while  a  ligature  is  tied  around  the  base  of  the  cone 
formed  by  that  part  of  the  wall  drawn  out  in  the  grasp  of  the  forceps.  If  the 
ligature  includes  the  entire  wound  periphery  and  is  properly  tied,  the  result  is 
satisfactory,  as  the  low  blood  pressure  in  the  veins  will  not  force  the  ligature 
off. 

Suture  of  Veins 

In  considering  the  suture  of  veins  certain  anatomical  points  regarding  their 
structure  must  be  kept  in  mind.  The  wall  is  thinner,  less  elastic  and  more 
flaccid  than  in  arteries  and  they  are  more  easily  torn.  They  require  more 
stitches  in  anastomosis  than  do  arteries  to  prevent  leakage  and  their  edges 
must  be  everted.  They  are  more  liable  to  thrombus  formation  on  account  of 
slower  blood  current  and  less  liable  on  account  of  the  constituency  of  the  blood. 

It  is  interesting  to  note  the  diiferent  opinions  voiced  regarding  the  rela- 
tive ease  of  accomplishment  of  a  vein  suture  as  compared  with  the  same  pro- 
cedure in  arteries.  Matas  says,  for  example:  "The  suture  may  be  applied  to 
veins  in  continuity  (lateral  phleborrhaphy)  in  longitudinal,  oblique  and 
transverse  wounds.  The  rules  which  govern  the  technic  of  arterial  suture 
apply  here  with  the  same  force  and  with  greater  advantage.  The  thinness, 
softness  and  suppleness  of  the  venous  walls  make  them  more  amenable  to  the 
suture  than  the  arteries.  The  low  tension  of  the  venous  current  also  favors 
the  maintenance  of  accurate  apposition  without  tension  and  favors  the  work 
of  repair.  The  suture  of  veins  is,  therefore,  not  only  a  much  easier  procedure 
than  the-  suture  of  arteries,  but  the  healing  of  the  line  of  suture  takes  place 
with  regTilarity,  provided  sepsis  has  been  rigorously  excluded."  Jeger,  on  the 
other  hand,  says :  "...  suture  of  veins  presents  various  difficulties  not 
present  in  arterial  suture. 

"With  the  latter,  the  lumen  remains  wide  open  on  account  of  the  thick- 
ness of  the  wall ;  it  is  plainly  visible  even  in  very  small  arteries,  and  one  may 
accomplish  all  the  procedures  (suture,  adaptation  of  the  vessel  ends  to  each 
other,  and  so  forth)  with  the  fullest  exposure  of  the  vessel  wall  and  almost 
without  the  use  of  a  forceps;  and  if  one  has  first  properly  inserted  the  three 
tension  sutures,  the  margins  of  the  vessels  automatically  rest  properly  together 
throughout  the  whole  circumference.  Quite  otherwise  is  the  case  with  veins. 
These  collapse  after  being  fully  divided;  the  lumen  is  often  only  to  be  dis- 
covered after  long  search ;  the  vein  must  be  held  open  with  instruments,  so 
there  is  naturally  much  handling  of  the  walls  with  forceps,  and  consequently 
numerous  lesions  of  the  endothelium  itself  are  unavoidable.  It  is  indeed  true 
that  the  circular  suture  of  veins,  in  the  hands  of  many  experimenters,  has 
afforded  as  good  or  better  results  than  circular  arterial  suture,  but  this  is 
founded  on  the  greater  diameter  of  the  veins  and  perhaps  also  on  the  some- 
what less  active  tendency  to  coagulation  in  the  venous  blood.  In  order  to  pro- 
ceed quite  safely,  one  must  absolutely  refrain  from  the  above-mentioned 
sources  of  failure." 


288  OPEKATIOXS    UPOX    BLOOD    VESSELS 

Lateral  suture  of  veins  is  indicated,  to  repair,  in  any  important  vein,  a 
wound  too  extensive  for  lateral  ligature.  It  is  contra-indicated  by  any 
phlebitis,  periphlebitis,  or  infection  of  wound. 

The  operative  technic  is  the  same  as  that  for  similar  repair  in  arteries 
except  that,  instead  of  direct  apposition  of  cut  edges,  care  is  taken  to  secure 
slight  eversion  of  wound  margins  so  as  to  insure  fairly  broad  intimal  approxi- 
mation. This  can  be  done  with  more  certainty  by  mattress  suture  than  by 
overhand  stitch,  either  continuous  or  interrupted.  The  object  is,  of  course, 
to  avoid  the  possibility  of  inversion  of  the  cut  edges,  which  is  much  more 
likely  to  occur  here  than  in  arterial  suture  on  account  of  the  thinness  and 
pliability  of  the  vein  wall.  Such  an  inversion  leads  to  rapid  thrombus 
formation. 

Results. — The  results  of  lateral  suture  of  veins  are  excellent. 


Venous  Anastomosis 

Venous  anastomosis,  like  arterial,  may  be  done  end-to-end,  end-to-side,  or 
side-to-side,  but  in  human  beings  the  end-to-end  is  the  only  method  that  has 
been  used  with  any  frequency. 

End-to-End. — The  indications  and  contra-indications  are  the  same  (as  ap- 
plied to  veins)  as  those  given  for  end-to-end  arterial  anastomosis. 

The  technic  of  a  circular  venous  suture  is  exactly  similar  to  that  of  a 
circular  suture  of  arteries,  already  described,  except  for  the  management  of 
the  cut  margins  of  the  veins;  these  should  be  somewhat  everted  instead  of 
being  brought  edge  to  edge,  so  that  intimal  apposition  is  assured.  To  accom- 
plish this  Jeger  recommends  the  following  procedure : 

Open  the  lumen  of  both  segments  of  veins  by  grasping  the  margins  of 
each  in  three  mosquito  clamps  placed  at  equal  intervals,  and  insert  3  traction 


Fig.  57. — Vein  Anastomosis,  End-to-end;  Application  of  Tension  Sutures  to  Provide  Ever- 
sion OF  Cut  Edges. 

sutures,  at  equal  intervals,  as  shown  in  diagTam  (Fig.  57).  These  are  longi- 
tudinal "U"  sutures  whose  nearer  limb  is  3  mm.,  aiid  whose  further  is  4  mm., 
from  the  cut  edge.  By  first  drawing  tight  and  then  tying  these  3  sutures  the 
lips  of  the  approximated  venous  segments  are  slightly  cuffed  and  the  usual 
continuous  suture  along  the  three  sides  of  the  triangulated  lumen  completes 


OPERATIOXS    UPOX    VEIXS  289 

the  anastomosis.  This  method  avoids  inckidiiig,  in  the  surface  that  is  to  be 
exposed  to  the  blood  stream,  any  part  of  the  intima  that  has  been  handled 
by  force]3s,  and  Jeger  says  the  results  are  absolutely  faultless. 

Carrel,  too,  mentions  the  necessity  of  everting  the  edges  of  veins  and 
says  they  are  ''united  not  by  their  surface  of  section,  but  by  their  endothelial 
surface."  ]\rurphy's  or  Payr's  method  of  invagination  may,  of  course,  be 
used;  but  neither  of  them  promises  as  good  results  as  have  already  been 
achieved  by  the  Carrel  suture.  The  Lespinasse  and  Eisenstaedt  method  has 
not  yet  apparently  been  tried  in  a  hmnan. 

Jeger  and  Janeway  have  both  devised  special  instruments  to  facilitate  the 
approximation  of  venous  segments  for  end-to-end  anastomosis. 

EESULTS. — Theoretically,  it  would  appear  that  the  dangers  of  suturing  a 
vein  were  more  formidable  and  the  chances  of  untoward  sequelae  greater  than 
in  the  sutures  of  arteries.  In  the  first  place  the  veins  are  apparently  more 
susceptible  to  infection  than  the  arteries.  In  the  second  place  any  foreign 
matter,  as  air,  tissue,  dirt,  bacteria,  etc.,  allowed  to  enter  the  vein  at  the  anas- 
tomotic site,  travels  toward  the  central  dangerous  region  instead  of  going  toward 
the  comparatively  safe  periphery,  as  it  does  when  introduced  into  an  artery. 
And,  lastly,  this  same  condition  holds  good  with  regard  to  possible  loose  por- 
tions of  such  a  clot  as  unfortunately  forms  in  a  certain  per  cent,  of  cases  at  the 
anastomotic  site.  Thus  we  should  expect  local  infection,  thrombo-angitis,  pul- 
monary embolism,  and  similar  unfortunate  results  of  blood  vascular  infection 
more  often  in  venous  than  in  arterial  sutures.  Such,  however,  is  not  apparently 
the  case. 

Statistics  show  little  difference  between  the  percentage  of  successful  results 
in  end-to-end  anastomosis  of  veins  and  of  arteries.  Glasstein,  for  example, 
reckons  62 lA  per  cent,  successes  for  circular  suture  of  veins,  in  a  series  of  53 
collected  cases  in  humans,  and  68  per  cent,  successes  for  circular  suture  of 
arteries  in  a  similar  series  of  37  collected  cases.  One  hates  to  appear  critical 
of  optimism,  but  it  would  seem  possible  that  he  has  not  too  high  a  standard 
of  success,  judging  his  deductions  by  those  of  others. 

Results  in  Veins  of  Animals. — The  results  of  circular  suture  of  veins 
in  animals  as  quoted  by  Jeger  are  shown  below  and  may  be  noted  in  connec- 
tion with  Glasstein's  statistics : 

Stich  reports  2  cases,  1  successful  =  50  per  cent,  successes ;  Borst  and 
Enderlen  report  14  cases,  1  successful  =  50  per  cent,  successes ;  Yamanouchi 
reports  43  cases,  24  successful  =  56  per  cent,  successes. 

It  is  interesting  to  find  that  certain  authors  claim  better  results  in  venous 
than  in  arterial  suture.  Schiller  and  Lobstein  claim  over  40  per  cent,  success 
with  arterial  suture  and  60  per  cent,  with  venous  circular  suture. 

End-to-Side. — The  only  practical  application  of  an  end-to-side  venous 
anastomosis  that  has  been  made  in  human  surgery  so  far  is  the  re-implantation 
of  the  saphenous  into  the  femoral  vein ;  and  the  technic  of  the  suture  opera- 
tion will  be  found,  further  on,  among  procedures  designed  to  remove  the  cause 
20 


290 


OPERATIONS    UPO]ST    BLOOD    VESSELS 


of  circulatory  disturbances  due  to  varicose  veins.  The  technic  of  Jeger's 
metliod,  however,  may  properly  be  detailed  here. 

The  anastomosis  may  be  made  by  suture  in  precisely  the  same  manner  as 
described  under  arteriovenous  anastomosis,  end-to-side. 

Jeger  recommends,   as  simpler  and  giving  absolute  assurance  of  perfect 


mrngrmwrmr 


Fig.  58. — Vein  Anastomo- 
sis, End-to-side.  Jeger's 
method:  3-loop  suture  in- 
serted in  larger  vein  and 
dotted  line  showing  inci- 
sion. 


Fig.  59. — Vein  Anastomosis,  End-to-side. 
Jeger's  method:  introducing  small  vein 
into  side  of  larger. 


endothelial  apposition,    a   method   he   and  Wilhelm   Israel   devised,   using  a 

Payr's  ring  and  a  special  Jeger  clamp  to  manipulate  it  (Fig.  21)  as  follows: 

The  smaller  vein  is  sufficiently  freed,  clamped  and  prepared  and  its  cut 

end  is  then  passed  through,  cuffed  back  over  and  tied  upon  the  ring  by  a  fine 

silk  ligature.  A  three-loop  suture  is  then  introduced 
through  the  wall  of  the  larger  vein  as  shown  in  Figure 
58  and  the  needles  are  cut  off,  leaving  a  middle  and 
two  lateral  loops.  A  small  incision  is  then  made  be- 
tween the  limbs  of  the  middle  loop  after  isolating  this 
portion  of  the  vein  with  a  small,  special  curved  clamp 
(Fig.  6).  The  clamped  off  portion  of  the  vein  is  then 
washed  and  vaselined,  its  edges  held  up  by  traction 
sutures  and  the  smaller  vein  placed  within  its  aper- 
ture (Fig.  59).  The  middle  loop  is  then  carefully 
tightened  and  securely  tied  upon  that  part  of  the  cuff 
of  the  smaller  vein  that  contains  the  ring,  the  ligature 
fitting  snugly  into  its  furrow  (Fig.  60).  Lastly,  the 
two  lateral  loops  are  tied  and  the  ends  of  these  and  the  traction  sutures  cut  short. 
Jeger  has  done  23  implantations  of  renal  vein  into  vena  cava  (on  animals) 
by  this  method  with  only  one  thrombus. 

Side-to-Side. — The   only  notable   application   of   the   lateral  venous    anas- 
tomosis in  human  surgery  so  far  is  the  Eck  fistula,  done  for  hepatic  cirrhosis 


Fig.  60. — Vein  Anastomo- 
sis, End-to-side.  Jeger's 
method:  smaller  vein  in- 
troduced, middle  loop  tied 
on  ring  and  ends  cut  off. 
Lateral  sutures  being 
tied. 


OPEEATIOIN^S    ITPOX    VEI^^S 


291 


by  Eosenstein.  The  description  of  the  operati^'e  steps  in  performing  an  Eck 
fistula  operation  comes  properly  under  operations  on  the  liver,  etc.,  but  the 
technic  of  the  suture  itself  is  exactly 
the  same  as  that  described  under 
arteriovenous  anastomosis,  side-to- 
side,  by  suture. 

Jeger  has  devised  a  three-bladed 
clamp,  closely  resembling  a  minia- 
ture Roosevelt  gastro-enterostomv 
clamp  (Fig.  61)  by  the  aid  of  which 
he  says  he  can  do  an  Eck  fistula  on  a 
dog  in  35  minutes.  Its  mode  of  appli- 
cation is  shown  in  Figure  62  and  the 
technic  of  the  suture  is  otherwise  the 
same  as  before.  Jeger  advises  oval 
pieces  to  be  excised  from  the  vein 
walls  instead  of  mere  slits  being- 
made,  as  the  latter  show  a  tendency  to 
close  spontaneously,  just  as  in  the  case  of  arteriovenous  anastomosis 


Fig.  61. — Jeger's  3-blade  Clamp  for  Isolating 
Parts  of  Two  Vessels  without  Interrupt- 
ing THE  Circulation  in  the  Remainder. 
Section  of  blades. 


Tkansplantation  of  Veins 

The  transplantation  of  veins,  as  regards  vascular  surgery,  means  the  re- 
placement of  a  defect  in  any  vessel  by  a  segment  removed  from  some  other 
vessel,  practically  always  a  vein  and  practically  always  of  the  same  individual. 


Fig.  62. — Vein  Anastomosis,  Side-to-side  :  Jeger's  Clamp  Shown  Isolating  Parts  of  the  Vena 
Cava  and  Vena  Porta  without  Interrupting  Circulation  through  Remainder  of  Veins. 
End,  middle  and  lateral  traction  sutures  and  posterior  layer  of  continuous  suture  shown. 


This  is  called  autoplastic  transplantation  as  differentiated  from  homoplastic, 
and  heteroplastic,  and  has  been  more  successfully  used  than  any  other  variety 


292  OPEEATIO^^S    UPOX    BLOOD    VESSELS 

tlius  far.  So  many  successful  homoplastic  and  heteroplastic  transplantations, 
however,  have  been  done  on  animals  that  it  is  possible  any  day  may  see  the 
report  of  some  such  cases  in  human  patients.  Transplantation  may  be  used 
to  fill  a  defect  caused  by  excision,  crushing,  etc.,  of  part  of  a  vessel  whose 
simple  ligation  would  be  dangerous  to  the  life  of  the  part. 

Besides  simple  autoplastic,  Guthrie  suggests  other  material  that  might  be 
used  to  fill  defects  in  vessels : 

(1)  Similar  vessels  from  another  human  being, — homoplastic; 

(2)  Vessels  from  a  different  species,  sheep,  etc. — heteroplastic; 

(3)  Cold  storage  tissues  (not  recommended  on  account  of  possible  putre- 
factive autolytic  change  in  them)  ; 

(4)  Eormaldehyd  fixed  tissue  (safer  than  cold  storage)  ; 

(5)  Possibly,  tissues  not  of  animal  origin  might  be  used;  tubes  of  cel- 
loidin,  glass,  etc. ; 

(6)  Von  Llagen,  quoted  by  Jeger,  advises  calves'  arteries  fixed  in  the  fol- 
lowing manner :  10  per  cent,  formalin  solution ;  water  washing ;  increased 
alcohol  strengths ;  absolute  alcohol ;  xylol  till  fully  cleared ;  liquid  paraffin 
over  night.  Such  vessels  showed  no  sign  of  absorption  after  six  months.  They 
were  encapsulated  in  connective  tissue. 

Methods. — The  actual  union  consists  of  a  double  end-to-end  suture  as  de- 
scribed under  end-to-end  arteriovenous  or  venous  anastomosis,  but  several 
points  are  to  be  mentioned  that  do  not  come  up  for  discussion  under  those 
operations. 

To  supply  a  defect  in  femoral,  popliteal,  brachial,  or  axillary  artery,  a 
piece  of  internal  saphenous  vein  may  be  excised.  This  must  be  a  little  longer 
than  the  defect  to  be  bridged  and  can  be  trimmed  to  suit  with  sharp  scissors. 
Before  final  suture  at  both  ends  it  should  be  between  ^^  inch  to  1/4  ii^ch  shorter 
than  the  arterial  defect  when  artery  ends  are  naturally  retracted.  If  it  is  too 
short  it  will  put  too  much  strain  on  the  sutures.  If  too  long  it  will  form  a 
curve  in  the  line  of  the  artery  when  the  blood  is  allowed  to  fiow  through  it.  If 
valves  exist  in  the  removed  seg-ment  of  vein  it  should  be  reversed,  in  its  new 
position,  so  that  the  blood  current  may  not  be  obstructed  by  the  valves. 

It  is  better  to  -insert  the  3  tension  sutures  at  each  end  of  the  transplant 
before  beginning  the  continuous  suture  at  either  end. 

If  the  vein  is  much  larger  than  the  artery  Jeger  advises  that  the  latter  be 
cut  after  Dobrowolskaja's  method  to  meet  more  nearly  the  size  of  the  vein. 
(Fig.  63.)  Guthrie  and  Carrel  advise  longer  stitches  in  the  vein  than  in  the 
artery,  all  around  the  circumference,  to  accommodate  its  lumen  to  that  of  the 
artery.  Jeger  also  advised,  in  excising  the  vein  for  a  transplant,  to  cut  partly 
through  it  and  apply  a  mosquito  clamp  to  the  cut  edge,  cut  further  and  repeat 
this  procedure  twice,  so  as  to  identify  front  and  back  or  sides  of  the  transplant, 
by  the  3  or  4  clamps  at  equal  intervals,  which  also  serve  to  spread  the  lumen 
for  application  of  tension  sutures. 

Unger  has  small,  numbered  clamps,  4  of  which  he  attaches  in  this  manner 


OPEEATIONS    UPON    VEINS 


293 


w 


to  the  upper  and  lower  ends  of  the  transplant  while  excising  it,  and  these  serve 
to  prevent  the  transplant  becoming  twisted  on  its  long  axis  without  the  opera- 
tor noticing  it.  These  clamped  portions  must  not  come  in  contact  with  the 
blood  stream  when  both  lines  of  suture  have  been  completed. 

Boothby  describes  a  method  for  setting  stay  sutures  before  the  vein  is 
removed  for  transplantation:  (1)  The  vein  is  freed  for  2  inches  or  more  and 
is  ligated  at  both  ends.  (2)  Grasp  vein 
with  smooth  forceps  near  upper  liga- 
ture and  cut  very  small  aperture.  (3) 
Insert  a  suture,  from  without  in,  near 
the  aperture  and  make  it  emerge 
through  this.  (4)  Repeat  this  procedure 
twice  at  upper  end  and  three  times  at 
lower  end  of  segment  until  3  stay  su- 
tures are  prepared  at  each  end,  at  equal 
distances  apart.  (5)  Then  divide  the 
transplant  beyond  these  sutures  and,  by 
means  of  them,  attach  it  to  the  ends  of 
the  defective  vessel  in  its  new  position. 

Operative  Steps. — The  steps  of  oper- 
ation of  free  vein  transplantation  to  fill 
an  arterial  defect  are:  (1)  Prepare 
ends  of  resected  artery,  as  described  in 
end-to-end  arterial  anastomosis  by  su- 
ture, and  cover  them  with  liquid  albo- 
lene.  Pack  the  tissue  wound  loosely 
with  wet  gauze  sponges  after  measuring 
length  of  arterial  defect.      (2)  Expose 

internal  saphenous  vein  near  saphenous  opening  by  a  liberal  incision.  Isolate 
it  carefully  and  thoroughly  from  its  bed  for  a  sufficient  distance  and  measure 
off  on  its  freed  portion  a  length  14)  inch  greater  than  the  arterial  defect.  (3) 
Apply  distal  and  then  proximal  temporary  hemostasis  beyond  this  portion  and 
ligate  and  divide  any  intervening  tributaries.  (4)  Fix  and  identify  ends  of 
transplant  by  Jeger's,  Unger's  or  Boothby's  method  (previously  described)  and 
excise  the  included  segment  of  vein.  (5)  Wash  out  all  blood  immediately, 
cover  it  inside  and  out  with  liquid  albolene  and  protect  it  in  moist  warm 
gauze.  (6)  Uncover  a-rtery,  reverse  transplant,  end-for-end  (to  obviate  obstruct- 
ing blood  current  by  valves),  and  lay  it  in  the  arterial  defect.  (7)  Connect  each 
end  to  the  arterial  stump  by  three  traction  sutures,  using  care  not  to  twist  the 
vein  on  its  long  axis,  and  unite  by  continuous  suture,  as  described  in  end-to-eud 
arteriovenous  anastomosis  (Eig.  64).  (8)  Remove  temporary  hemostasis,  apply 
pressure  and  add  complementary  sutures  as  indicated.  (9)  Close  wound  of 
exposure  for  artery  and  saphenous  veins. 

Results. — The  results  are  exemplified  in  the  report  of  these  cases. 


Fig.  63.  —  Cutting  Abteky  to  Match  Vein 
AND  Putting  in  Stay  Sutukes. 


294  OPEKATIOISTS    UPOI^    BLOOD    VESSELS 

Goyanes,  in  1906,  excised  popliteal  aneurysm  and  filled  defect  with  piece 
of  vein.     Successful  result. 

Delbet,  in  1906,  filled  an  8  cm,  defect  due  to  removal  of  aneurysm  in  one 
person  by  a  transplant  of  artery  from  another  individual  whose  limb  was 
being  amputated  at  the  same  time.  The  operation  failed  as  the  transplanted 
artery  was  sclerotic  and  the  sutures  tore  through.  The  femoral  artery  had 
to  be  ligated.    Result :    amputation. 

Lexer,  in  1907,  transplanted  8  cm.  of  vein  into  a  defect  of  axillary  artery, 

caused  by  removal  of  aneu- 


rysm.     Result:    death  from 
delirium  tremens,  fifth  day. 


.mjJjjwjvjM^.  ^  ljmjw,i»wn  Doyen,  in  1909,  in  a  pa- 

^^^/yj^yJMO////M///JJJy^j!I^^  tient  with  edema  of  leg  fol- 

„   "     ,      ,  ^  _.  _  -_  lowing    excision    of    part    of 

liG.  64. — Arterial  Defect  Filled  by  Double  End-to-  . "  .  ^ 

END  Suture  with  Venous  Transplant.  popliteal  vein  for   aneurysm, 

implanted  the  external  jugu- 
lar of  a  sheep,  end-to-side  in  popliteal  vein,  above  the  obliterated  area,  and 
joined  it  end-to-end  with  the  posterior  tibial  vein  after  making  a  subcutaneous 
canal  for  it.  The  operation  resulted  in  complete  healing,  but  he  does  not  men- 
tion whether  the  edema  was  relieved. 

Enderlen,  in  1909,  after  resecting  part  of  femoral  artery  for  sarcoma, 
transplanted  15  cm.  of  saphenous  vein  from  another  limb.  Result:  smooth 
healing. 

Goeckes,  in  1912,  reported  the  excision  of  a  right  popliteal  aneurysm. 
An  8  cm.  defect  was  filled  by  a  10  cm.  transplant  from  left  saphenous  vein,  set 
with  valves  favoring  flow  of  blood.  The  operation  was  immediately  success- 
ful. Pulsation  in  posterior  tibial  was  felt  strongly  at  once  and  beginning  gan- 
grene of  foot  healed.  After  14  days,  however,  the  tibial  pulse  grew  weak  and 
the  wound  broke  down  and  a  small  fistulous  tract  persisted.  The  clinical 
result,  however,  was  good  and  the  patient  was  able  to  go  freely  about.  He 
died  5  months  later  from  abscess  of  knee-joint  and  endarteritis  of  coronary 
arteries.  In  the  vessel,  thrombi  occluding  it  were  found  at  both  suture  lines, 
on  autopsy. 

Omi,  in  1912,  reported  that  he  had  excised  a  right  popliteal  aneurysm 
leaving  a  defect  of  about  8  cm.  This  he  filled  with  an  8  cm.  piece  of  the  left 
saphenous  vein,  by  circular  suture.  He  forgot  to  reverse  the  vein  and  the 
valves  held  the  blood  back.  He  then  divided  the  vein  at  valve  level,  resected 
the  valves  and  did  a  circular  suture  of  the  cut  vein  ends.  Good  pulsations 
appeared  in  vein  and  peripheral  part  of  artery,  but  were  not  felt  in  posterior 
tibial  or  dorsalis  pedis.  Gangrene  developed  in  foot  in  a  few  days ;  patient 
refused  amputation  and  died  in  a  short  time. 

After  excision  of  popliteal  aneurysm,  in  another  case,  leaving  a  defect  of  Y.5 
cm.,  he  filled  it  with  an  8  cm.  piece  of  femoral  vein,  reversed  so  as  to  favor 
passage  of  blood  through  valves,,  by  Carrel  circular  sutures.     Pulse  felt  after 


OPERATIONS    UPON    VEINS  295 

operation  in  dorsalis  pedis  and  posterior  tibial  artery.  Excellent  result,  ap- 
parently permanent. 

Omi  recommends  autoplastic  vein  transplantation  in  human  beings,  at 
present,  as  safest. 

EESULTS  IN  ANIMALS. — Venous  transplantation  in  animals  shows  a 
higher  percentage  of  success  than  in  man.  According  to  the  reports  of  Fischer, 
Schmieden,  Watts,  Stich,  Yamanouchi,  Borst  and  Enderlen,  as  collected  by 
Jeger,  we  find  iii  autoplastic  transplantation  42.8  per  cent,  and  in  homo- 
plastic transplantation  28.6  per  cent,  successes,  where  the  transplant  was  made 
into  the  cervical  vessels  of  dogs. 

OPERATIONS    FOR    DRAINAGE    OF    CAVITIES,    ETC. 

The  transplantation  of  veins  for  purposes  other  than  that  of  repairing  de- 
fects in  blood  vessels  may  here  be  mentioned,  although  the  operative  details 
belong,  and  will  be  given,  under  regional  headings. 

Eitter  has  reported  the  use  of  free  transplanted  veins  and  arteries,  as  cov- 
ering for  and  connections  for  divided  tendons  and  nerves,  with  some  success. 

Unger  and  Bettmann,  in  1910,  reported  the  use  of  pieces  of  transplanted 
vein  (fresh  or  cold  storage)  to  press  upon  a  defect  in  the  sinus  longitudinalis 
with  resultant  closure  of  woimd  by  adhesion  of  pieces  of  vein. 

Jeger  says  that  Tietze  attempted  unsuccessfully  to  cure  a  gonorrheal  stric- 
ture by  excising  a  6  cm.  portion  of  the  urethra  and  replacing  it  by  a  9  cm. 
transplant  of  saphenous  vein ;  and  that  Becker  attempted,  with  partial  success, 
to  construct  a  urethra  in  two  cases  of  severe  hypospadias  by  drawing  a  piece 
of  saphenous  vein  through  a  canal  made  by  a  trocar  in  the  penis ;  while  Stet- 
tiner  constructed  a  practicable  urethra,  in  a  case  of  hypospadias,  out  of  a  12 
cm.  piece  of  saphenous  vein.  Taupas  of  Athens,  Von  Eiselberg  and  Miihsam 
have  done  similar  operations. 

Pouotte,  in  1907,  and  Castle,  in  1911,  have  reported  two  successful  veno- 
peritoneostomy operations.  Henle  and  Bakay,  Payr,  and  also  McClure  used 
pieces  of  saphenous  vein  (also  of  artery)  to  drain  ventricles  of  the  brain  and 
a  transplant  of  the  external  jugular  vein  to  drain  the  subdural  space. 

OPERATIONS    TO    ALTER    BLOOD    OR     CIRCULATION    FOR     STIMULATION    OR 

medication 

Intkavenous  Injection 

By  this  is  meant  the  injection  of  a  soluble  drug  or  other  fluid  through  a 
hollow  needle  directly  into  a  vein,  usually  of  the  arm.  It  may  be  used  where 
the  rapid  and  direct  action  of  any  soluble  curative  agent,  as,  for  example, 
injections  of  salvarsan  in  syphilis  and  of  blood  serum  in  anemia  and  hemo- 
philia, are  required.     The  preparation  of  the  solution  will  be  described  under 


296  OPEKATIONS    UPOIST    BLOOD    VESSELS 

the  appropriate  therapeutic  heading,  but  the  technic  of  the  injection  is  as 
follows : 

(1)  The  left  arm,  preferably,  is  bared  to  the  shoulder  and  the  antecubital 
region  either  cleansed,  as  in  general  operative  field  preparation,  or  painted  with 
tr.  iodin,  which  is  washed  off  with  alcohol  after  being  allowed  to  dry.  (2) 
A  constricting  band  of  rubber,  gauze  or  muslin  is  placed  around  the  middle 
of  the  arm  sufficiently  tight  to  obstruct  the  venous  return  and  dilate  the  super- 
ficial veins.  (3)  The  vein  (median  basilic  usually  selected)  is  steadied  be- 
tween thumb  and  finger  of  left  hand  and  the  needle,  which  must  be  very  sharp 
and  smooth,  held  like  a  scalpel  between  the  thumb  and  fingers  of  the  right 
hand,  is  thrust  rapidly  and  carefully  through  the  skin  into  the  dilated  vein. 
Eree  bleeding  through  the  lumen  announces  its  entrance,  whereupon  the  con- 
strictor is  removed.  The  needle  should  enter  the  vein  very  obliquely  so  as 
to  avoid  puncturing  the  opposite  wall  and  must  be  held  steady  after  entrance 
to  avoid  scratching  the  intima.^  (4)  The  shaft  of  the  needle  is  steadied  in  the 
left  hand;  the  syringe  is  held  vertical,  nozzle  upward,  in  the  right  hand,  and, 
after  expelling  all  the  air,  is  inserted  carefully  into  the  needle  and  the  injec- 
tion made  slowly  and  steadily.  (5)  The  needle  is  then  rapidly  and  carefully 
withdrawn  and  pressure  made  with  the  fingers  on  a  gauze  pad  over  the  punc- 
ture for  two  or  three  minutes.  A  dry  dressing  is  then  strapped  on  in  its  place. 
(6)  Careless  or  unskillful  introduction  of  the  needle  may  wound  the  opposite 
wall  of  vein  with  a  resultant  hematoma  and  no  free  bleeding  from  needle.  It 
is  possible  to  wound  the  brachial  artery  which  lies  beneath  the  median  basilic, 
separated  from  it  only  by  deep  fascia.  If  these  accidents  are  avoided  and 
proper  asepsis  practiced,  there  are  no  bad  results. 


Intravenous  Infusion 

Intravenous  infusion  is  the  direct  introduction  through  a  cannula  into  the 
venous  system  of  a  considerable  amount  of  solution  for  the  purpose  of  increas- 
ing the  fluid  contents  of  the  vessels  and  raising  blood  pressure. 

Solutions. — So-called  normal  saline  is  most  commonly  used.  This  is  pre-- 
pared  by  adding  6  to  8  parts  of  sodium  chlorid  to  100  of  filtered  water.  It  is 
sterilized  by  boiling  or  by  steam  under  pressure.  Other  solutions  that  have 
been  tried  are : 

Ringer's  Fluid: 

Potassium  chlorid 0.2  gm. 

Sodium  bicarb 0.2  gm. 

Sodium  chlorid   9.0  gm. 

Distilled  water  q.  s.  add  1  liter. 

^  Steps  (1),  (2),  and  (3)  of  this  procedure  may  be  followed  to  obtain  specimen  of 
blood  for  Wassermann  test,  etc.;  in  such  ease  the  constrictor  is  not  removed  until  the  re- 
quired amount  of  blood  has  been  obtained.     . 


OPERATIONS    UPON    VEINS  297 

Locke's  Fluid  (more  satisfactory  in  its  effect)  : 

Potassium  chloric! 0.10  to     0.20  gm. 

Sodium   bicarb 0.10  to     0.20  gm. 

Calcium   chlorid    0.20  gm. 

Glucose    1.0     gm. 

Sodium  clilorid   9.0     to  10.0     gm. 

Distilled  water,  1  liter. 

Kuttner's  Solution: 

Decinormal   saline   solution 1,000  c.  c. 

Oxygen  gas  (approximately) 20  c.  c. 

These  solutions  are  sterilized  in  the  same  way  as  simple  saline  solution. 

TEMPERATURE  OF  FLUID. — Temperature  of  fluid  should  be  from  105° 
to  120°  F.,  in  the  container,  depending  on  the  size  and  length  of  tubing 
through  which  it  has  to  flow  to  the  cannula.  Temperature  of  fluid  leaving  the 
latter  should  be  not  over  105°  F. 

PRESSURE  OF  FLUID. — Reservoir  of  fluid  should  be  only  about  12  inches 
(30  cm.)  above  vein.  Greater  height  gives  unnecessary  and  even  injurious 
pressure. 

TIME  OF  INFUSION. — Infusion  should  not  be  given  faster  than  1,000  c.  c. 
in  10  to  20  minutes. 

AMOUNT  OF  FLUID. — In  adults  500  to  1,000  c.  c.  may  be  used  or  more  ac- 
cording to  patient's  reaction  as  expressed  in  rise  of  blood  pressure. 

Much  larger  amounts  of  saline  than  of  blood  are  tolerated.  More  can  be 
given  with  benefit  in  treatment  of  hemorrhage  than  in  treatment  of  shock, 
and  Locke's  solution  is  perhaps  preferable  for  patients  in  an  exhausted  condi- 
tion. Adrenalin  1 :  1,000  may  be  added  to  the  solution  in  amounts  of  10  to 
20  minims  or  may  be  injected  by  a  hypodermic  syringe  (after  Crile)  into  the 
rubber  tube  near  the  cannula  at  the  rate  of  10  or  15  minims  in  one  minute. 

Infusion  has  been  used  for  acute  anemia  resulting  from  operative  or  post- 
operative, traumatic,  pulmonary,  gastric,  intestinal,  uterine,  etc.,  hemorrhage; 
in  gTeat  loss  of  body  fluid,  as  in  Asiatic  cholera ;  for  flushing  the  vascular  sys- 
tem, in  acute  poisoning,  auto-intoxication,  such  as  typhoid,  diabetic  coma, 
puerperal  fever,  eclampsia  gravidarum,  bubonic  plague,  uremia,  and  blood 
poisoning,  following  venesection ;  for  resuscitation  in  suspended  animation 
(Locke's  solution  injected  into  -carotid  artery  with  reversal  of  current)  ;  in 
chronic  postoperative  anemia  and  for  artificial  nutrition  (Locke's  and  Len- 
nander's  glucose  saline  solution ;  or  sterile  isotonic  sea-water,  plasma  de  Quin- 
ton). 

Binnie  says  (1912)  :  "The  principal  indications  for  intravenous  infusion 
of  salt  solution  are  shock  and  hemorrhage.  Hypodermoclysis  and  proctoclysis 
have  largely  taken  the  place  of  intravenous  infusion." 

Certainly  saline  infusions  are  less  commonly  used,  and  hypodermocly- 
sis and  proctoclysis  are  more  often  employed  than  they  were  several  years 
ago. 


298 


OPEKATIONS    UPO:^^    BLOOD    VESSELS 


Infusion  is  contra-indicated,  according  to  Matas,  "in  all  cases  where  there 
is  already  a  dilatation  with  distention  of  the  heart  and  consequently  general 
venous  stasis."  The  condition  is  evidenced  by  cyanosis  of  face  and  extremities 
and  overfilling  of  the  superficial  veins. 

Instruments,  etc.,  required  are  forceps,  scalpel,  ligature  carrier,  ligatures, 
cannula,  tubing  and  reservoir,  salt  solution,  skin  suture,  dressings. 

Method. —  (1)  Select  the  arm  least  used  by  the  patient  and  surround  it  by 
a  constrictor  midway  between  elbow  and  shoulder,  sufficiently  tight  to  dilate 
superficial  veins.  Prepare  the  skin  of  the  antecubital  region  by  washing  or  by 
applying  tr.  iodin.  (2)  Select  the  most  prominent  vein,  usually  median  basilic 
or  cephalic;  anesthetize  locally  with  0.5  per  cent,  novocain  and  adrenalin,  and 

incise  skin  and  fascia  over  it  longitudinally  or 
obliquely  for  about  1  inch.  Expose  and  isolate 
the  vein  by  sharp  dissection  and  free  it  suffi- 
ciently to  pass  a  double  catgut  ligature  around  it 
in  an  aneurysm  needle.  (3)  Tie  the  distal  liga- 
ture permanently ;  set  a  loose  friction  knot  in  the 
proximal  ligature.  Cut  a  triangular  flap  in  the 
superficial  surface  of  the  vein,  between  ligatures, 
with  its  apex  pointing  distally.  Occlude  the 
opening  by  finger  pressure  of  left  hand.  (4) 
Grasp  the  cannula  in  the  right  hand ;  hold  it  ver- 
tical and  allow  fluid  to  flow  till  all  air  is  got  rid 
.  •      ;  ;  .1  of.     Then  grasp  the  tip  of  vein  flap  with  forceps 

\         ;  j  I         in  the  left  hand  and  introduce  the  cannula  into 

'  the  lumen  while  solution  is  flowing   (Fig.   65). 

(5)  Tighten  the  friction  knot  upon  the  cannula 
and  place  a  finger  on  the  vein,  proximal  to  it,  to 
regTilate  rate  of  flow.  Let  it  be  very  slow  at  first, 
increasing  gradually  to  the  rate  of  1,000  c.  c.  in  20  minutes.  Allow  the  fluid 
to  flow  until  observations  of  the  pulse,  taken  every  minute  or  two,  show  a  return 
toward  normal  tension.  In  most  cases  less  than  2,000  c.  c.  are  enough  to  accom- 
plish this  if  it  can  be  done  at  all.  (6)  Remove  the  cannula,  solution  still  flow- 
ing ;  tighten  the  friction  knot  in  proximal  ligature  and  reinforce  it.  Close  the 
skin  wound  by  sterile  adhesive  or  silk  suture,  apply  gauze  dressing  and 
bandage. 

The  operation  is  a  very  simple  one,  except  in  fat  people  with  small  veins 
or  when  the  superflcial  veins  are  empty  on  account  of  low  blood  pressure.  In 
such  cases  it  may  be  difficult  to  find  a  vein  and  the  brachial  artery  has  occa- 
sionally been  opened  in  the  search  for  the  median  basilic  vein. 

Too  rapid  introduction  of  saline  may  overwhelm  an  already  weakened 
heart  and  do  more  harm  than  good.  Too  large  an  infusion  may  result  in 
transudation  into  serous  cavities. 

Any  superficial  vein  may  be  used  instead  of  the  antecubital. 


Fig.  65.  —  Intravenous  Infu- 
sion: Cannula  Introduced 
INTO  Vein  at  Elbow. 


OPERATIONS    UPON    VEINS  299 

Slowly  and  carefully  given  infusions  are  undoubtedly  of  \^alue  in  cases  of 
hemorrhage  and  shock,  and  bad  results,  such  as  every  surgeon  occasionally  sees, 
are  generally  due  to  haste  and  carelessness.  But,  except  in  urgent  cases,  the 
results  in  raising  blood  pressure  and  replacing  lost  body  fluids  are  no  better 
than  those  from  hypodermoclysis  and  proctoclysis,  very  much  simpler  and 
easier  procedures. 

Blood  Transfusion 

Blood  transfusion  is  the  transference  of  blood  from  the  circulation  of  one 
individual  to  that  of  another.  It  may  be  accomplished  by  joining  the  vessels 
by  suture  or  tube  (direct  transfusion)  or  by  w^ithdrav^^ing  blood  from  one  indi- 
vidual into  a  syringe  or  vessel  and  then  injecting  it  into  the  other  individual 
(indirect  transfusion).  In  the  recent  past  the  direct  method  has  been  more 
used,  but  the  indirect  method  is  gaining  ground  at  present  on  account  of  its  ease, 
simplicity,  and  the  ability  to  measure  the  amount  of  blood  transfused. 

In  1909  Crile  v^^rote:  "The  question  as  to  what  pathologic  condition  may 
be  suitably  treated  by  transfusion  of  blood  from  one  human  being  to  another 
has  not  been  definitely  settled.  The  most  that  can  be  said  at  present  is  that  it 
is  clearly  indicated  in  certain  conditions  and  as  clearly  contra-indicated  in 
certain  others.  With  our  present  knowledge  the  author  feels  that  it  should 
be  used  only  when  all  other  resources  at  command  have  failed." 

Since  that  time  transfusion  has  been  found  serviceable  in  cases  of  acute 
anemia  from  hemorrhage  of  traumatic,  operative,  or  other  origin,  such  as 
gastric  or  typhoid  ulcers,  ruptured  extra-uterine  pregnancies,  etc.  It  has  been 
used  with  some  success  to  raise  the  blood  resistance  of  anemic  patients  as  a 
preliminary  to  operation. 

It  has  been  used  a  number  of  times  iu  pernicious  anemia  without  perma- 
nent benefit  in  most  cases.  In  melena  neonatorum  it  has  proved  most  valuable 
and  its  use  in  hemophilia  in  general  has  been  satisfactory.  In  illuminating 
gas  and  carbon  monoxid  poisoning,  and  others  where  methemoglobin  is  formed, 
Crile  has  resuscitated  a  number  of  cases  by  transfusion.  Cole  recommends  it 
in  pellagra.  Surgical  shock  has  been  treated  satisfactorily  by  transfusion. 
Certain  toxemias  (as  of  pregnancy)  seem  to  be  amenable  to  it. 

Infectious  diseases,  such  as  scarlet  fever,  and  septicemias,  such  as  staphy- 
lococcus, have  been  treated,  and  perhaps  improved. 

Walter  has  tried  infusing  pernicious  anemias  with  blood  of  polycythemics. 
Delbet  has  suggested  infusing  typhoid  patients  with  blood  of  those  who  have 
had,  and  survived,  an  attack  and  show  a  strong  immunity.  Lilienthal  says: 
"In  transfusion  in  typhoid  the  donor  should  always  be  one  with  acquired  im- 
munity, to  avoid  replacing  the,  at  least  partially,  immune  blood  of  recipient  by 
non-immunized  blood."  (Personal  communication.)  Bevan  says  there  is 
evidence  of  its  value  in  sarcoma.  Jeger  recommends  it  also  in  jaundiced 
people,  before  serious  operation,  to  prevent  bleeding. 


300  OPERATIOIs^S    VFON    BLOOD    VESSELS 

E.  H.  Pool,  in  a  personal  communication  in  regard  to  the  nse  of  transfusion 
in  jaundiced  patients,  says:  "The  case  to  which  I  referred  was  a  woman 
about  35.  She  had  extreme  jaundice  as  a  result  of  a  stone  in  the  com- 
mon duct.  She  received  calcium  lactate  for  some  days  before  operation, 
but  we  did  not  give  her  serum  because  she  had  received  considerable  serum  a 
few  months  before  for  a  very  severe  streptococcus  septicemia,  and  I  was  afraid 
of  anaphylaxis.  About  48  hours  after  the  operation  for  stone  in  the  common 
duct  she  began  to  ooze  extensively  until  she  was  practically  moribund.  Her 
coagulation  time  was  15  minutes.  A  transfusion,  using  her  sister  as  donor, 
was  made  with  marked  improvement,  but  after  three  days  the  oozing  recurred 
and  the  patient  again  got  into  extremely  bad  condition,  so  that  a  transfusion 
was  again  performed  and  the  coagulation  time  dropped  from  15  to  6  minutes; 
the  oozing  stopped  and  the  patient  made  an  uneventful  recovery  from  that 
time. 

"I  am  inclined  to  think  that  this  is  the  first  case  in  which  transfusion  has 
been  performed  for  postoperative  oozing  in  jaundiced  patients.  The  drop  in 
the  coagulation  time  from  15  minutes  to  6  was  striking. 

"Subsequently,  a  patient,  an  old  man  with  a  stone  in  the  common  duct,  was 
markedly  jaundiced  and  I  did  a  preliminary  transfusion  and  operated  im- 
mediately afterward.     He  had  no  postoperative  oozing." 

Jeger  says  it  is  absolutely  contra-indicated  in  the  presence  of  organic  heart 
disease,  because  the  heart  is  not  equal  to  any  suddenly  increased  work,  and 
Dorrance  and  Ginsberg  say  that  it  is  contra-indicated  in  any  case  where 
hemolysis  is  taking  place,  as  in  purpura  hemophilia. 

Eor  direct  transfusion  from  artery  to  vein  the  radial  artery  of  donor  and 
one  of  the  superficial  veins  at  the  elbow  of  the  recipient  are  generally  em- 
ployed. Occasionally  the  internal  saphenous,  or  some  other  superficial  vein, 
may  have  to  be  employed  on  account  of  infection,  etc.,  at  elbow.  Either  left 
or  right  side  may  be  chosen  according  as  donor  is  right  or  left-handed. 

The  instruments  required  for  any  direct  transfusion  are  the  usual  dissect- 
ing outfit  of  scalpel,  dissecting  forceps,  scissors,  artery  forceps,  serrefines, 
catgTit,  and  silk  ligatures  and  sutures.  Special  appliances,  such  as  Crile's 
cannula.  Brewer's  tubes,  etc.,  will  be  described  in  connection  with  the  descrip- 
tion of  their  method  and  use. 

Whatever  method  of  transfusion  is  employed,  however,  there  are  certain 
common  details  that  should  be  observed  preliminary  to  and  during  the  opera- 
tion.    These  we  may  now  consider  under  the  term 

General  Management  of  Transfusion. — In  every  case  where  time  is  allowed 
and  facilities  are  at  hand  several  blood  pressure  determinations  should  be 
taken  and  several  pulse  rate  estimations  made.  A  complete  red  blood  cell 
count  and  white  blood  cell  count  and  hemoglobin  estimation  should  be  secured 
on  both  donor  and  recipient  before  transfusion  is  begun;  the  last  to  serve  as  a 
basis  for  comparison  with  similar  examinations  after  the  operation  is  over  and 
during  the  after  care.     The  two  former  are  to  serve  as  standards  for  compari- 


OPERATIONS    UPON    VEINS  301 

son  with  similar  observations  made  during  the  progress  of  transfusion,  obser- 
vations upon  vv^hich,  in  part,  the  operator  bases  his  judgment  as  to  the  proper 
duration  (or  amount  of  blood  transfused)  for  the  transfusion  flow. 

Hemolysis  and  agglutination  tests  of  donor's  and  recipient's  blood  should 
also  be  made,  if  possible ;  but  the  necessary  omission  of  any  of  these  prelimi- 
naries and  precautions  does  not  contra-indicate  the  operation  by  any  means. 
(Bernheim.)     Lilienthal  thinks  hemolysis  and  agglutination  tests  imperative. 

A  careful  examination  of  the  donor  should  be  made  to  discover  any  signs 
of  disease  that  might  make  the  use  of  his  blood  dangerous  for  the  recipient. 
This  examination  ought,  if  possible,  to  include  serum  reactions  for  syphilis 
and  gonorrhea,  unless  the  donor  is  known  to  be  free  from  any  suspicion  of 
venereal  disease. 

Each  patient  should  be  given  %  to  1/4  grain  of  morphin  (unless  contra- 
indicated)  30  minutes  before  operation,  and  should  be  reassured  as  to  pain, 
danger,  etc. 

During  the  transfusion  Bernheim  recommends  controlling  the  inflow  of 
blood  by  finger  pressure  on  the  vein  throughout  the  whole  operation,  and,  if 
assistants  are  at  hand,  taking  observations  of  pulse  rate  and  blood  pressure  of 
recipient  every  3  minutes;  of  donor,  every  5  minutes.  His  routine  is  "to  at- 
tempt to  bring  a  pulse  of  say  150  or  160  down  to  about  100  and  to  raise  a 
blood  pressure  of  50  or  70  up  to  110  or  120,  figures  well  within  the  zone  of 
safety."  But  he  warns  against  the  danger  of  raising  too  much  the  blood  pres- 
sure of  a  patient  suffering  from  the  results  of  internal  hemorrhage,  as  from 
typhoid  ulcers.  He  adds  that  it  is  most  difficult  to  judge  at  all  exactly  of  the 
amount  of  blood  transfused,  but  that  the  pulse  and  blood  pressure  observa- 
tions, the  knowledge  gained  by  the  fingers  and  thumb  guarding  the  entrance  to 
the  vein,  the  general  appearance  of  the  recipient,  and  the  actual  time  the  blood 
has  been  flowing,  all  serve  as  guides  to  the  proper  time  to  end  the  transfusion. 
He  estimates  the  duration  of  actual  flow  to  average  in  most  transfusions  20  to 
40  minutes ;  the  range  being  3  to  5  minutes  to  1  hour  or  II4  hours,  according 
to  the  size  of  the  recipient.  He  says  donor's  indications  for  ending  trans- 
fusion are  a  "sudden  fall  of  20  to  30  points  in  blood  pressure,  or,  lacking  ap- 
paratus for  blood  pressure  determination,  sudden  pallor,  accompanied  by 
nausea  and  vomiting,  continued  and  increasing  thirst,  great  restlessness,  to- 
gether with  a  decrease  in  blood  pressure  as  shown  by  the  finger  of  the  operator, 
in  the  donor's  radial." 

Bevan  recommends  having  such  operating-tables  that  the  Trendelenburg 
position  may  be  used  for  the  donor  and  the  reverse  Trendelenburg  for  the 
recipient  in  order  to  better  manage  a  possible  anemia  of  the  donor  or  a  cardiac 
dilatation  of  the  recipient. 

Jeger,  too,  insists  upon  the  gradual  beginning  of  the  transfusion  flow  and 
warns  one  to  stop  if  any  sign  of  cardiac  dilatation  appears  in  the  recipient, 
and  wait  10  minutes  before  continuing  the  flow.  Especially  in  little  children, 
he  says,  are  symptoms  of  cardiac  weakness  carefully  to  be  watched  for. 


302  OPERATION'S    UPOX    BLOOD    VESSELS 

Lilieiithal,  who  has  had  a  wide  experience  in  transfusion  operations,  does 
not  think  it  necessary  to  slow  the  flow  with  the  fingers  as  Bernheim  does.  He 
watches  the  recipient  carefully  for  signs  of  dilated  heart,  and  uses,  as  signs 
for  stopping  transfusion,  dyspnea,  cyanosis,  rapid  irregular  pulse  of  recipient, 
and  faintness  of  donor.  He  prefers  the  hemoglobin  estimations  as  an  indi- 
cation of  how  much  blood  to  transfuse,  and  has  estimations  taken  every  3  to  5 
minutes  on  recipient  during  the  flow,  and  endeavors  to  raise  the  percentage  to 
somewhere  near  double  its  original  point.  He  does  not  think  it  safe  to  more 
than  double  it,  and  he  has  doubled  it  in  19  minutes  in  one  case  (personal  com- 
munication). 

In  speaking  of  the  donor,  Crile  says :  "The  best  way  of  determining  when 
to  stop  the  flow  is  by  watching  his  (donor's)  symptoms.  At  first  he  will  show 
loss  of  color  in  his  mucous  membrane,  pallor  of  the  skin,  slight  uneasiness, 
slight  quickening  of  pulse  and  respiration,  lowering  of  blood  tension,  and  be- 
ginning shrinkage  in  the  skin  of  the  face.  All  of  the  symptoms  are  progres- 
sive, and  as  soon  as  they  are  well  marked  the  flow  should  be  stopped.  Often 
the  condition  of  the  recipient  will  necessitate  this  long  before  the  donor  shows 
any  symptoms  at  all."  Concerning  the  recipient,  Crile  says  that  too  rapid  a 
flow  may  be  prevented  by  partially  narrowing  the  lumen  of  the  artery  by 
gentle  finger  pressure,  shutting  off  the  flow  altogether,  if  necessary,  for  short 
intervals,  to  give  the  heart  a  chance  to  assume  the  added  burden  gradually. 
Crile  mentions  the  possibility  of  infecting  the  donor  in  transfusions  performed 
for  infectious  diseases,  as  typhoid,  and  advises  selecting  immune  donors.  He 
thinks  there  is  little  risk  in  cases  of  chronic  infection  like  tuberculosis,  or  from 
an  old  septicemia  or  mixed  infection.  So  far  as  the  recipient  is  concerned, 
Crile  says  the  chief  danger  is  cardiac  dilatation.  Fortunately  a  certain  amount 
of  dilatation  may  occur  and  pass  rapidly  away,  as  shown  by  his  series  of  cases. 

He  mentions  that  preliminary  bleeding  may  be  advisable  in  certain  cases. 
'Not  in  shock  or  acute  hemorrhage,  of  course,  and  rarely  in  subacute  hemor- 
rhage; but  in  all  other  cases  either  preliminary  bleeding  is  required  or  less 
blood  must  be  transfused ;  for  blood  is  retained  in  the  vascular  system  where 
saline  infusion,  for  example,  passes  rapidly  out  of  it.  Bleeding  and  trans- 
fusion may  be  practiced  synchronously  in  feeble  patients  with  marked  reduc- 
tion of  red  corpuscles. 

Crile  says :  "When  acute  dilatation  has  once  occurred  it  must  be  promptly 
recognized.  Transfusion  must  be  stopped,  table  tilted  to  put  patient  in  head 
up  position,  and  rhythmic  pressure  made  over  heart."  If  recovery  is  not 
complete  in  a  short  time  the  transfusion  should  be  given  up,  patient  put  to 
bed  in  "head  up"  posture,  given  carefully  graded  doses  of  nitroglycerin  to 
insure  peripheral  dilatation  of  vessels,  and  digitalin  hypodermically  in  very 
small  doses  to  stimulate  heart  muscles  directly.  Small  doses  of  morphin  also 
are  advised. 

Crile  gives  no  very  definite  rule  as  to  how  much  blood  should  be  given  the 
recipient.     "Enough  blood  must  be  transfused  to  accomplish  as  much  good  as 


OPERATIONS    UPON    VEINS  303 

possible,  and  yet  too  much  must  not  be  given.  Sometimes  in  cases  where  the 
patient  does  not  suffer  from  the  loss  of  a  large  amount  of  blood  it  seems  to  be 
as  advantageous  to  transfuse  a  small  as  a  large  amount.  The  symptoms  of  the 
recipient  give  the  best  key  to  the  situation." 

AMOUNT  OF  BLOOD  TO  BE  TKANSFUSED.^ — In  children  a  small  amount 
only  is  needed  in  most  cases.  Cooley  and  Vaughan  report  a  recovery  from 
melena  neonatorum  after  the  transfusion  of  only  20  c.  c.  of  blood.  On  the 
other  hand,  Peck  has  transfused  an  amount  of  blood,  in  the  case  of  an  adult, 
estimated  at  2,000  c.  c.  In  general  it  vi^ould  appear  that  1,000  c.  c.  is  enough 
for  most  adults,  and  children  require  correspondingly  less. 

The  amount  of  blood  passed  may  be  measured : 

(a)  By  bleeding  donor's  vessel  into  a  test-tube  for  30  seconds  and  multiply- 
ing the  resulting  amount  by  twice  the  number  of  minutes  the  transfusion  flow 
lasts  (direct  method).  This  is  inaccurate  on  account  of  variation  in  pulse 
rate  and  blood  pressure  and  lumen  of  vessels. 

(b)  By  receiving  blood  into  a  receptacle  (syringe,  pipette)  which  accurately 
measures  it  (indirect  method). 

Methods  of  Direct  Transfusion. — AETERY-TO-VEIN  METHOD. — Ceile's  Can- 
nula.— Crile's  cannula  is  one  of  the  earlier  and  better  known  instruments  for 
facilitating  transfusion.  It  is  on  the  principle  of  Payr's  ring,  but  furnished 
with  a  handle,  which  may  be  grasped  by  a  hemostat  (Fig.  66).  His  descrip- 
tion of  the  technic  follows : 

"Experience  has  shown  that  it  is  best  to  use  a  radial  artery  of  the  donor  and  any 
superficial  arm  vein  of  the  recipient  near  the  elbow.     Usually  the  median  basilic  vein 
is  the  best  on  account  of  its  size  and  easily  ac- 
cessible position.     Local   anesthesia   is   obtained 
by  injecting  cocain  in  1/10  of  1  per  cent,  solu- 
tion with  a  few  drops  of  1  to  1,000  adrenalin.^ 
Several  hypodermic  syringes  should  be  ready,  so 
that  there  should  be  no  delay  on  account  of  hav- 
ing to  stop  and  refill  a  single  one.     The  injec- 
tions are  first  made  into  the  skin  and  then  more 
deeply  around  the  vessels.     After  this,  firm  pres- 
sure is  applied  by  the  hand  over  a  gauze  sponge  Fig.  66. — Chile's  Cannula. 
to  insure  spreading  the  cocain  through  the  tis-  (Size  greatly  exaggerated.) 
sues.     When  carefully  performed,  there  is  abso- 
lutely no  pain  in  any  part  of  the  technique  until  the  sutures  are  placed  in  the  skm  at 
the  end  of  the  transfusion.    By  then  the  effect  of  the  cocain  has  usually  worn  away. 

"In  making  the  dissection,  it  is  necessary  to  have  good  light.  Mosquito  hemostats 
are  used  to  catch  every  vessel  that  sheds  even  a  drop  of  blood.  The  field  should  be 
kept  alisolutely  clean.  The  donor's  radial  artery  is  isolated  for  a  distance  of  about 
3  cm.  at  the  point  of  injection  in  the  wrist.  Here  there  are  a  number  of  side  branches 
which  must  be  carefully  isolated  and  tied  with  No.  1  Chinese  twist  silk  (which  has 
not  been  split  up  into  strands)  before  being  cut.  The  artery  is  then  tied  at  its  distal 
end  and  a  'Crile'  clamp  is  gently  screwed  in  place  over  the  proximal  part  as  near 
1  Other  operators,  Bernheim  and  Lilienthal,  warn  against  the  use  of  adrenalin  chlorid 
solution. 


304 


OPERATIONS    UPOIsT    BLOOD    VESSELS 


to  the  place  where  it  comes  out  of  the  undissected  tissue  as  convenient.     The  clamp 
should  be  screwed  up  with  great  care. 

"Just  enough  pressure  should  be  used  to  control  the  flow  of  blood  without  causing 
injury  to  the  vessel  wall.  The  artery  is  severed  with  sharp  scissors  a  short  distance 
from  where  it  is  tied  off,  the  end  cut  squarely  across,  the  adventitia  pulled  down  and 
cut  off.  The  result  should  be  that  the  operator  has  about  two  and  a  half  cm.  exposed 
radial  artery  free  from  branches.  The  next  step  is  the  dissection  of  the  vein.  It  is 
exposed  for  the  same  distance  as  the  artery,  the  branches  tied  off  in  the  same  way, 
and  the  ligature  is  also  applied  to  the  distal  end.     The  second  'Crile'  clamp  is  applied 


Fig.   67. — Chile's   Method   of  Anastomosis  for  Transfusion  with  Cannula. 


just  as  before,  the  vein  cut  near  the  ligature  and  it,  in  turn,  is  ready  for  the  comple- 
tion of  the  anastomosis.  After  selection  of  a  cannula  of  suitable  size  (as  large  a 
size  should  be  used  as  possible  without  injuring  the  intima  of  the  artery  by  stretch- 
ing it  too  much),  the  end  of  the  vein  is  either  pushed  through  the  handle  end  of  the 
cannula  with  the  help  of  fine-pointed  forceps,  or  pulled  through  by  means  of  a  single 
fine  suture  inserted  in  its  edge,  the  needle  being  left  on  the  suture  and  passed  through 
the  cannula  ahead  of  the  vein.  The  handle  of  the  cannula  is  then  tightly  seized  by 
a  pair  of  hemostats,  three  mosquito  forceps  are  snapped  at  equidistant  points  on  the 
end  of  the  vein,  taking  care  not  to  have  the  tips  extend  up  into  the  lumen  more  than 
is  necessary  to  get  a  firm  hold.  The  end  of  the  vein  is  then  cuffed  back  over  the 
cannula  by  gentle  traction  on  the  hemostat  and  tied  firmly  in  place  with  a  fine  linen 
thread  in  the  groove  nearest  the  handle.  The  cuffed  part  is  then  covered  with  sterile 
vaseline,  being  careful  not  to  get  any  in  the  open  end.  The  three  hemostats  are  then 
applied  to  the  edges  of  the  artery,  just  as  with  the  vein;   (it  may  be  necessary  to 


OPERATIONS    UPON    VEINS  305 

dilate  the  end  very  gently  by  inserting  the  closed  jaws  of  a  mosquito  heraostat  cov- 
ered with  vaseline  and  opening  them  very  gently  for  a  short  distance)  and  the  artery 
is  gently  drawn  over  the  cuffed  vein  on  the  cannula  and  tied  in  place  with  another 
fine  linen  suture  in  the  remaining  groove.  Ail  the  hemostats  are  removed.  The 
venous  and  then  the  arterial  clamps  are  removed  and  the  blood  allowed  to  flow.  The 
exposed  vessels  should  be  kept  moist  with  warm  saline."     (Fig.  67.) 

Elsberg's  objections  to  Crile's  cannula  arei 

''Some  experience  is  required  before  the  Crile  instrument  can  be  handled 
with  ease. 

"The  caliber  of  the  cuffed  vessel  is  decreased  by  the  cannula. 

"Sometimes  there  is  difficulty  in  telescoping  the  artery  over  the  vein. 

"The  steps  of  the  operation  with  Crile's  cannula  are  numerous  and  the  ap- 
plication of  the  guide  suture  and  tying  of  ligatures  complicates  the  operation." 

With  the  exception  perhaps  of  the  last,  these  objections  apply  also  to 
Buerger's,  Bernheim's,  and  Hepburn's  modification  of  Crile's  instrument. 

Elsbekg's  Cannula. — Elsberg's  cannula  seems,  by  general  consent,  to  be 
the  most  satisfactory  instrument  yet  devised  for  the  direct  method  of  trans- 
fusion.    His  own  description  of  it  and  of  the  technic  of  transfusion  follows: 

"The  cannula  is  built  on  the  principle  of  a  monkey  wrench,  and  can  be  enlarged 
or  narrowed  to  any  size  desired  by  means  of  a  screw  at  its  end.  (Fig.  68.)  The 
smallest  lumen  obtainable  is  about  equal  to  that  of  the  smallest  Crile  cannula,  and  the 
largest,  greater  than  the  lumen  of  any  radial  artery.  The  instrument  is  cone-shaped 
at  its  tip,  a  short  distance 
from  which  is  a  ridge  with 
four  small  pin  points,  which 
are  directed  backward.  The 
lumen  of  the  cannula  at  its 
base  is  larger  than  at  the  tip. 
The  construction  of  the  can- 
nula can  easily  be  understood 
from  the  following  descrip- 
tion of  the  method  of  using  it. 
The  radial  artery  of  the  donor  Fig.  68. — Elsberg's  Cannula. 

is  exposed  and  isolated  in  the 

usual  manner.  The  cannula,  screwed  wide  open,  is  then  slipped  under  and  around  the 
vessel.  It  is  then  screwed  shut  until  the  two  halves  of  the  instrument  slightly  com- 
press the  vessel. 

"The  artery  is  then  tied  off  about  one  centimeter  from  the  tip  of  the  cp.nnula. 
Before  the  vessel  is  divided,  three  small  eye  tenaeula  are  passed  through  the  wall  of 
the  artery  at  three  points  of  its  circumference,  a  few  millimeters  from  the  ligature. 
Small  mosquito  forceps  may  also  be  used.  These  are  given  to  an  assistant,  who  makes 
traction  on  them  while  the  operator  cuts  the  vessel  near  the  ligature.  The  moment 
the  artery  is  cut,  the  stump  is  pulled  back  over  the  cannula  by  means  of  the  tenaeula 
or  forceps,  and  is  held  in  place  without  ligation  by  the  small  pin  points.  There  is 
no  bleeding  from  the  artery  even  though  no  hemostat  clamps  have  been  used,  be- 
cause the  cannula  itself  acts  as  a  hemostatic  clamp.  The  vein  of  the  recipient  is  then 
exposed  (but  not  freed),  two  ligatures  are  passed  around  it;  one  is  tied  peripherally 
in  the  usual  manner.  A  small  transverse  slit  is  then  made  in  the  vein;  the  cannula 
21 


306  OPEEATIOIsTS    UPO^    BLOOD    VESSELS 

with  the  cuffed  artery  inserted  into  the  vein;  a  ligature  tied  around  the  vein  and 
cannula;  the  cannula  screwed  open,  and  the  blood  allowed  to  flow.  The  rapidity  of 
the  flow  can  be  varied  as  much  as  desired  by  the  size  to  which  the  instrument  is 
screwed  or  unscrewed,  and  the  lumen  of  the  artery  is  never  diminished. 

"It  will  be  noticed  that  the  artery  is  cuffed  instead  of  the  vein.  This  method  I 
believe  to  be  more  correct.  The  vein  is  the  larger  vessel  and  can  therefore  be  more 
easily  telescoped  over  the  artery.  The  vein  is  only  exposed,  not  freed,  and  the  artery 
is  intubated  into  it.  With  this  cannula  I  have  been  able  to  make  the  anastomosis 
in  less  than  four  minutes  after  the  artery  has  been  isolated  and  have  found  the  entire 
procedure  a  simple  one.  The  advantages  of  the  instrument  are  the  following:  (1) 
The  cannula  will  fit  any  vessel;  (2)  the  cannula  is  applied  around  the  vessel  instead 
of  the  vessel  being  drawn  through  the  cannula;  (3)  no  ligature  of  the  cuffed  vessel 
is  required;  (4)  the  cannula  itself  acts  as  a  hemostatic  clamp;  (.5)  the  cuffing  of  the 
artery  is  easily  accomplished  without  stripping  back  the  adventitia,  and  therefore 
the  traumatism  to  the  artery  wall  is  reduced  to  a  minimum;  (6)  the  vein  needs  only 
be  exposed,  not  dissected  out  and  cut;  (7)  as  the  cannula  is  unscrewed,  the  blood  will 
flow ;  the  flow  can  be  regulated  at  will,  and  the  lumen  of  the  artery  is  not  diminished." 

Lilientlial  and  also  Elsberg  now  prefer  the  direct  vein-to-vein  over  the 
artery-to-vein  method,  and  recommend  Elsberg's  cannula  as  being  the  best 
means  for  accomplishing  the  anastomosis. 

Beknheim's  Tube. — One  of  the  most  recently  devised  appliances  for  the 
direct  artery-to-vein  method  is  the  transfusion  tube  of  Bernheim. 

"It  is  a  two-pieced  af- 
fair (Fig.  69)  consisting 
of  two  hollow  tubes,  each 
4     cm.     long,     and     each 

Fig.  69.— Bernheim's  2-piece  Transfusion  Tube.  DuIdouS   at   one   end   m   or- 

der to  form  a  neck  for  a 
retaining  tie,  and  beveled  to  facilitate  entrance  into  the  vessel;  the  other  ends 
are  tubular  and  fitted  for  invagination." 

He  says  that  it  is  especially  useful  in  transfusing  infants  where  smallness 
of  the  parts  makes  actual  union  of  vessels  with  Crile  or  Elsberg  cannul£e  diffi- 
cult ;  and  in  emergencies  where  speed  is  desirable  the  separate  halves  of  the 
tube  can  be  inserted  in  the  two  patients  at  once  by  separate  operators.  This 
is  his  very  excellent  description  of  its  use: 

"The  radial  artery  is  dissected  out  as  follows,  novocain  (0.5  per  cent.)  being  the 
anesthetic  of  choice:  (1)  Expose  the  artery  with  its  accompanying  veins  (just  above 
the  wrist  joint)  for  a  distance  of  about  two  inches;  (2)  free  the  artery  from  the 
veins  and  tie  off  all  branches  doubly  with  fine  silk,  cutting  between  the  ties;  (3)  tie 
off  the  artery  doubly  at  the  distal  end  of  the  wound  and  cut  between  ties,  thus  allow- 
ing about  one  and  one-half  inches  of  the  vessel  to  be  free  in  the  wound;  (4)  tie  off 
all  bleeding  points  in  the  wound,  and  keep  a  constant  stream  of  warm  salt  solution 
flowing  over  the  artery,  all  sponging  being  done  with  gauze  moistened  in  the  same 
solution;  (5)  place  a  bull-dog  clamp  on  the  vessel  at  the  proximal  end  of  the  wound. 
A  small  cut  is  now  made  in  the  upper  side  of  the  artery  with  a  pair  of  fine  scissors, 
the  opening  being  made  at  right  angles  to  the  course  of  the  vessel  and  about  half  its 
width.     Next,  every  visible  trace  of  blood  is  immediately  washed  out  in  warm  salt 


OPEEATIOl^S    UPON    VEINS 


307 


solution  find  liquid  vaseline,  the  latter  being  injected  into  the  lumen  of  the  vessel 
with  a  medicine  dropper  at  frequent  intervals  during  the  washing  process.  It  keeps 
the  vessel  soft  and  pliable,  and  prevents  too  rapid  evaporation  and  consequent  drying. 
Any  little  bit  of  adventitia  that  may  get  into  the  opening  should  be  carefully  pushed 
away  or  cut  off.  (6)  The  vessel  having  been  carefully  prepared,  the  beveled  end  of 
the  male  half  of  the  tube  is  inserted  into  the  artery  and  held  there  by  a  tie  thrown 
around  its  neck.  (Fig.  TO.)  Liquid  vaseline  is  again  injected  into  the  vessel  through 
the  tube,  and  the  whole  thing  wrapped  in  salt  solution  gauze  to  await  the  comple- 


FiG.  70. — Bernheim's  Method  of 
Transfusion:  Male  Half  of 
Tube  Tied  into  Radial  Artery. 


J 1/ 
CephalitV, 


Fig.  71. — Bernheim's  Method  of 
Transfusion:  Female  Half  of 
Tube  Tied  into  Vein  of  Recip- 
ient. 


tion  of  a  similar  preparation  of  the  vein  of  the  recipient.  (7)  It  is  hardly  necessary 
to  dissect  out  more  than  one  inch  of  the  vein,  and,  as  this  is  always  quite  superficial, 
the  time  required  for  the  whole  procedure  of  dissection,  cleansing  and  insertion  of 
the  female  half   of  the  tube   (Fig.   71)    amount  to  hardly  more   than  five  minutes. 

(8)  When  both  patients  have  been  prepared,  their  stretchers  are  brought  into  apposi- 
tion and  the  two  arms  are  placed  on  a  table  about  one  foot  broad.  With  a  little 
manipulation  the  wrist  of  the  donor  is  brought  into  such  proximity  to  the  elbow  of 
the  recipient  that  the  tubes   can  be  invaginated  to   the  proper   degree.      (Fig.   72.) 

(9)  When  this  is  accomplished,  a  steady  stream  of  warm,  saline  solution  is  started 
flowing  over  the  artery,  tube  and  vein,  and  the  bull-dog  clamp  is  removed  from  the 
vein,  its  place  being  taken  by  the  thumb  and  first  finger  of  the  operator.  With  great 
care  the  clamp  controlling  the  arterial  flow  is  now  gradually  released,  coincidently 
with  which  the  thumb  and  finger  controlling  the  vein  gradually  ease  up,  thus  permit- 
ting the  blood  to  go  over  gradually,  so  as  to  prevent  any  possibility  of  swamping  or 
embarrassing  the  circulation  of  the  recipient  by  a  sudden  gush  of  blood  under  great 
pressure." 


308 


OPEKATIOXS    UPOX    BLOOD    VESSELS 


If  clotting  occurs,  lie  removes  both  tubes,  washes  out  the  vessels  with 
saline  and  liquid  vaselin,  and  inserts  a  new  set  of  tubes,  the  flow  being  started 
in  the  usual  manner.  When  the  transfusion  is  finished  the  tubes  are  re- 
moved, the  vessel  ligated,  and  the  wound  sutured. 

Carrel's  Suture. — Carrel's  suture  was 
used  bj  Crile  before  he  devised  his  own  can- 
nula, and  has  been  used  by  many  other  oper- 
ators with  satisfaction.  The  technic  of 
the  suture  itself  has  been  described  under 
end-to-end  arteriovenous  anastomosis  by  su- 
ture. Pool  reported  a  series  of  transfusions 
in  1910  by  Carrel  suture.  Lilienthal  (per- 
sonal communication)  says  he  has  used  the 
suture  method  successfully  in  several  vein- 
to-vein  transfusions.  He  dissects  out  about 
3  inches  of  the  donor's  vein  at  the  elbow, 
leaving  a  certain  amount  of  superficial  fascia 
around  it  to  allow  of  easy  handling,  and  after 
freeing  about  one  inch  of  the  recipient's  vein 
(usually  basilic  or  cephalic,  at  the  elbow) 
he  prepares  the  ends  and  anastomoses  them 
by  the  method  of  Carrel. 

Jeger  says  that  the  Carrel  method  is  used 
by  Enderlen,  Hoercken,  and  Tufiier.  Hors- 
ley  also  uses  suture,  but  of  mattress  type  in- 
stead of  overhand.  Jeger  continues :  "The 
use  of  the  direct  vessel  suture  in  blood  trans- 
fusion has,  however,  the  disadvantage  of  being  exceeding  difficult.  Tuffier  in- 
forms us  that  Carrel  in  his  case  (at  Tuffier's  Clinic)  completed  the  vessel  suture 
in  five  minutes,  but,  in  the  hands  of  most  other  surgeons,  this  operation  would 
require  a  very  gTeat  deal  more  time," 

Brewer's  Tubes. — Brewer's  tubes  are  of  glass,  lined  with  paraffin,  about 


Fig. 


Bernheim's 


Method  of 
Transfusion:  Tubes  Invaginated 
AND  Anastomosis  Complete. 


Fig.  73. — Brewer's  Transfusion  Tube. 


3/16  of  an  inch  in  diameter  at  larger  end,  tapering  to  Vs  inch,  and  slightly 
flared  at  both  ends.  They  are  about  Sl/o  inches  long  and  have  a  double  bend 
(Eig.  73).  The  artery  and  vein  are  exposed  in  the  usual  manner,  and  the 
smaller  end  of  the  tube  is  slipped  into  the  artery,  the  larger  into  the  vein,  and 


OPEKATIOXS    UPOX    VEIXS 


309 


i=^ 


Shoulder  fo 

Shoulder  Tube- 

Fig.  74.  —  Fauntleroy's 
Modification  of  Brew- 
er's Tubes. 


tied  in  with  ligature.  The  flared  ends  of  the  tube  keep  the  vessels  from  slip- 
ping off.  The  objection  to  these  tubes,  as  stated  bv  Brewer,  is  that  the  lumeu 
is  too  small  to  allow  of  sufficient  flow.  This  objection  has  apparently  been 
obviated  in  the  modification  brought  out  by  Fauntleroy. 

Several   years    ago    Dorrance   and    Ginsberg    advised    direct    vein-to-vein 
transfusion ;  and  later  Fauntleroy  reported  the  use  of 
the  Brewer  tube  in  direct  vein-to-vein  transfusion. 
The   method    would    seem    an    excellent    emergency 
measure  where  special  cannulse  were  unobtainable. 

VElX-TO-VEl^r  METHOD. — Flare  the  ends  of  a 
piece  of  thin  glass  tubing  i/y  inch  inside  diameter  by 
heating  them  and  pushing  a  pointed  wire  nail  into 
the  lumen  while  hot  (Fig.  Y4).  Heat  the  tube  again 
and  bend  into  an  S-  or  F-shape  with  extremities  3 
inches  apart,  as  it  is  designed  to  have  the  hands  of 
the  patients  pointing  in  the  same  or  opposite  direc- 
tions. After  boiling  the  tubes,  drop  them  into 
melted  paraffin ;  lift  them  out  with  a  sterile  forceps, 
shake  excess  paraffin  out,  lay  in  sterile  gauze  to  cool, 
and  wipe  paraffin  off  their  outside.     They  are  then  ready  for  use. 

Make  the  superficial  veins  prominent  by  applying  a  constrictor  above  the 
elbow.  Expose  and  free  the  chosen  vein  of  the  recipient  for  about  1  inch. 
Pass  2  ligatures  around  it  at  the  ends  of  the  freed  portion ;  tie  the  distal  one 
and  remove  the  constrictor.  Expose  and  pass  ligatures  around  the  donor's 
vein  in  similar  fashion,  and  tie  the  proximal  one.  Temporarily  occlude  the 
distal  end  by  serrefine,  tape,  and  clamp,  etc. ;  open  the  donor's  vein  (or  divide 
it)  far  enough  above  this  to  slip  the  prepared  tube  distally  into  it,  and  tie  it  in 

place  with  the  distal  liga- 
ture. Lay  the  donor's  and 
recipient's  arm  side  by 
side  on  a  small  table  with 
the  elbows  at  the  same 
level,  and  opposite  each 
other.  Open  the  vein  of 
the  recipient  between  liga- 
tures, remove  the  tem- 
porary hemostatic  on  the 
donor's  vein;  allow  the  blood  to  fiow  through  tube  and  expel  the  air,  slip  the 
free  end  into  the  recipient's  vein,  and  tie  in  place  with  the  proximal  ligature 
(Fig.  75).  The  donor's  constrictor  is  left  in  place  to  keep  up  his  venous  pres- 
sure. When  sufficient  blood  has  passed  remove  the  tube,  ligate  the  veins,  and 
close  the  wound.  Fauntleroy  says  it  is  as  easy  as  a  saline  infusion:  Move- 
ment of  the  patients'  arms  must  be  guarded  against  on  account  of  angulating 
veins  against  ends  of  tube  and  causin<2:  clotting  of  blood. 


Fig.    75. 


-Yein-to-vein    Transfusion    with    S-shaped    Tube 
(Fauntleroy) . 


310 


OPERATIONS    UPOX    BLOOD    VESSELS 


Vincent  has  used  similar  tubes  with  satisfaction. 

The  Indirect  Method  of  Transfusion. — The  indirect  method  of  transfusion 
in  which  the  blood  is  passed  from  donor  to  recipient  by  the  medium  of  some 
form  of  container,  depends  for  its  success  upon  the  failure  of  the  blood  to  clot 
in  the  interval  between  its  withdrawal  from  the  former's  and  its  introduction 
into  the  latter's  veins.    Such  a  coagulation  seems  to  be  avoidable  in  three  ways : 

(1)  By  making  the  transference  so  rapidly  that  insufficient  time  for  clot- 
ting elapses  between  the  blood's  withdrawal  from,  and  its  reintroduction  into, 
normal  vascular  channels. 

(2)  By  "the  emplo^Tuent  of  an  intermediate  system,  providing  no  point 
of  contact  with  any  moistenable  surfaces,  and  at  the  same  time  minimizing  as 


Fig.  76. — Curtis  and  David's  Apparatus  for  Indirect  Transfusion. 


far  as  possible  the  exposure  of  broken  tissue  surface  to  the  blood  stream." 
(Satterlee  and  Hooker.) 

(3)  By  "the  emploj^ment  of  a  sufficient  amount  of  some  physiologic  agent 
(antithrombin)  to  restrain  or  offset  the  initiative  factors  of  coagulation  during 
the  time  of  the  conveyance  of  the  blood  through  a  foreign  system,  such  as  glass 
and  metal."     (Satterlee  and  Hooker.) 

Upon  the  first  of  these  principles  are  based  the  methods  of  Moritz  and 
Lindemann;  upon  the  second,  those  of  Curtis  and  David  and  Satterlee  and 
Hooker.  Experiments  are  now  under  way  to  determine  the  practical  value  of 
the  third  principle  (by  Satterlee  and  Hooker,  and  others). 

The  indirect  method  of  transfusion  has  recently  been  taken  up  by  a  num- 
ber of  men,  and  the  work  of  Moritz,  Curtis  and  David,  Risley  and  Irving, 
Lindemann,  Satterlee  and  Hooker  has  done  a  great  deal  toward  popularizing 
this  method. 

CUKTIS  AND  DAVID  METHOD.— Curtis  and  David  use  a  100  c.  c.  glass 
syringe  with  rubber  tube  attached  and  a  double  cannula  tipped  glass  bulb  of 
100  to  400  c.  c.  capacity  (Fig.  76).  The  glass  bulb  is  sterilized  by  the  dry 
method  and  the  inner  surface  coated  with  paraffin.  The  paraffin  coat  is  best 
applied  by  pouring  hot  paraffin  into  the  open  end  and  then  rotating  the  bulb 
to  secure  a  uniform  coat.     The  two  cannula  tips  are  then  heated  and  each  in 


OPEEATIONS    UPOisT    VEINS 


311 


turn  dipped  into  melted  paraffin,  and  shaken  to  make  a  thorough  coating  so 
as  to  keep  the  excess  from  occhiding  the  lumen.  The  syringe  and  rubber  tube 
are  prepared  by  boiling. 

"With  the  apparatus  now  ready  for  use,  a  one-half  inch  incision  is  made  over  the 
most  prominent  vein  of  the  elbow  region  in  both  donor  and  recipient  (using  con- 
strictors if  desired).  The  donor's  vein  is  then  clamped  (with  a  vessel  clamp)  at  the 
distal  end  of  the  incision,  stripped,  ligated  proximally,  cut  below  the  ligature  and 
washed  out  with  one  per  cent,  solution  of  sodium  citrate. 
The  recipient's  vein  is  ligated  distally,  stripped  toward  the 
heart  and  clamped  at  the  upper  end  of  the  incision  (with 
vessel  clamp),  cut  above  the  ligature  and  also  washed  out. 
The  cannula  tips  are  moistened  by  introducing  a  few  drops 
of  liquid  petrolatum  through  the  bulb  end,  then  inserted  into 
the  respective  veins  of  donor  and  recipient  and  ligated  in 
position.  Aided  by  the  use  of  a  shoulder  constrictor,  blood 
rapidly  enters  the  bulb  when  the  donor's  vein  is  released.  As 
the  blood  rises  in  the  tube,  a  covering  of  liquid  petrolatum 
is  added  to  relieve  surface  tension.  The  rubber  tube  is  now 
fitted  over  the  top  of  the  glass  bulb  and  the  tube  and  syringe 
are  used  to  produce  positive  and  negative  pressure,  as  de- 


No.   1.  No.  2. 

Fig.  77.^Kimpton's  Cylinder  for  Indirect  Transfusion,  Nos.  1  and  2. 

sired.  (The  bulb  usually  fills  without  resorting  to  suction.)  The  donor's  vein  is 
then  held  by  the  finger,  the  recipient's  vein  released  and  the  blood  introduced  into  the 
latter  at  any  desired  rate  of  flow.  When  the  bulb  is  nearly  empty,  the  recipient's  vein 
is  held  and  that  of  the  donor  released,  thus  allowing  the  bulb  to  again  become  filled 
with  blood,  after  which  the  process  continues  as  before." 


They  had  done  4  or  5  human  transfusions  by  this  method  successfully  when 
they  pablished  this  report,  passing  over  1,050  c.  c.  of  blood  in  one  case. 

Jeger  says  that  a  certain  advantage  of  the  Curtis  and  David  apparatus 
over  others  exists  in  its  ability  to  transfer  blood  into  the  arterial  (against  the 
current)  as  well  as  into  the  venous  system.  Such  an  ability  might  possibly  be 
made  use  of,  he  thinks,  in  a  centripetal  arterial  transfitsion  by  which  the 
blood  would  tend  to  be  forced  into  the  aortic  bulb  and  so  fill  the  coronary 
arteries  and  resuscitate  an  enfeebled  heart.  This  procedure  has  been  men- 
tioned by  Crile  and  Dolley. 


312  OPEKATIOXS    UPOIf    BLOOD    VESSELS 

KIMPTON  METHOD. — Kimpton  has  recently  published  a  method  very  simi- 
lar to  Curtis  and  David's.  He  uses  a  250  c.  c.  paraffin-lined  cylinder  of  his 
own  pattern,  having  a  lateral  tube  and  a  terminal  cannula  tip  (Fig.  77).  He 
exposes  the  antecubital  veins  of  donor  and  recipient  in  the  usual  manner,  al- 
lows the  tube  to  fill  from  the  former  by  venous  pressure,  and  then  injects  the 
blood  into  recipient's  vein  by  pressure  from  an  actual  cautery  bulb  pump 
which  he  attaches  to  the  lateral  tube  of  the  cylinder.  If  more  than  250  c.  c.  of 
blood  are  required  he  uses  a  fresh  tube  for  each  subsequent  injection.  He 
reports  15  successful  transfusions  by  means  of  this  apparatus,  and  Turnure,  in 
a  personal  communication,  tells  me  of  4  additional  successful  operations. 

COOLEY  AND  VAUGHAN  METHOD.— Cooley  and  Vaughan  injected  120 
to  150  c.  c.  of  human  blood  and  saline  (about  20  c.  c.  blood)  into  the  median 
basilic  vein  of  a  baby  exsanguinated  by  intestinal  bleeding  of  melena  neona- 
torum. An  attempted  vein-to-vein  anastomosis  by  Crile  cannula  having  failed 
on  account  of  small  size  of  child  and  lack  of  blood  in  father's  veins,  one  of  the 
operators  acted  as  donor  and  the  other  withdrew  from  his  basilic  vein  about 
8  c.  c.  of  blood  through  a  sharp  needle  into  a  10  c.  c.  glass  syringe  into  which 
1  c.  c.  of  saline  solution  had  previously  been  drawn.  One-half  c.  c.  of  saline 
was  then  sucked  in  and  the  mixture  of  blood  and  salt  solution  injected  through 
a  blunt  needle  into  the  baby's  already  exposed  vein,  the  womid  being  held 
open  by  two  sutures  of  catgTit.  About  2  minutes  elapsed  from  the  time  when 
the  sharp  needle  was  inserted  into  the  donor's  vein  until  the  injection  of 
blood  into  the  recipient's  vein  was  completed.  The  injection  was  repeated  in 
15  minutes  and  the  child  recovered. 

LINDEMAN'S  METHOD. — Lindeman  describes  his  present  technic  as  fol- 
lows: 

"The  entire  apparatus  consists  of  two  sets  of  cannulas,  two  tourniquets  and  twelve 
syringes.  .  .  . 

"Two  sets  of  cannulas  are  employed,  one  for  the  donor,  the  other  for  the  recipient. 
(Figs.  78  and  79.) 

"There  are  three  cannulas  to  each  set.  Each  cannula  telescopes  within  the  other, 
as  shown  in  Figure  79. 

"The  innermost  cannula  is  practically  a  hollow  needle.  The  hollow  needle  (Fig. 
79)  is  fitted  snugly  into  Cannula  2.  Cannula  2  is  5  mm.  shorter  than  the  needle  and 
is  fitted  snugly  into  Cannula  3.  Cannula  3  is  5  mm.  shorter  than  Cannula  2.  The 
proximal  ends  of  1  and  2  are  capped  with  stationary  thumbscrew  caps. 

"The  proximal  end  of  3  is  capped  with  a  receiver  to  fit  any  Eecord  syringe. 

"Cannula  3  is  2  inches  long.  The  caliber  of  this  cannula  is  the  same  as  the  tip 
of  a  Record  syringe. 

"In  very  small  infants  with  very  small  veins,  only  cannulas  1  and  2  are  employed, 
2  being  capped  with  the  receiver  to  fit  tip  of  syringe. 

"The  cannulas  I  now  use  are  made  of  platinum. 

"The  syringes  used  are  Record  syringes  of  new,  improved  type  with  a  capacity  of 
20  c.  c.  and  can  be  sterilized  with  95  per  cent,  alcohol,  20  minutes.  .  .  . 

"One  operator  manages  syringe  of  recipient.  Another  operator  manages  syringe 
of  donor.  An  assistant  stands  between  operators,  who  are  in  position  close  to  the 
assistant.     Donor  and  recipient  are  placed  in  the  recumbent  posture. 


OPEEATIONS    UPON^    VEINS  313 

"A  table  is  arranged  conveniently  between  them  so  that  a  nurse  can  wash  syringes 
as  rapidly  as  they  are  used.  For  this  purpose  two  basins  of  sterile  water  and  one 
basin  of  normal  saline  solution  are  used.  The  normal  saline  solution  is  used  in  the 
last  rinsing;  the  syringes  are  so  well  cleaned  in  the  first  two  rinsings  that  the  rinsing 
solution  remains  practically  clear. 

"In  adults  and  most  children  over  2  years  of  age  the  median  basilic  vein  is  easily 
accessible.     In  infants  the  external  jugular  or  one  of  its  tributaries  is  entered  more 


Fig.  78. — Lindeman's  Cannula,  Assembled. 

advantageously.  In  some  cases  the  internal  saphenous  may  prove  the  vein  of  prefer- 
ence. 

"A  tourniquet  is  placed  in  position,  and  the  skin  is  sterilized  with  iodiii.  The 
cannula  is  then  held  in  a  position  almost  parallel  to  the  vein  with  the  thumb  on  the 
thumb-screw  of  the  innermost  cannula  (Fig.  78,  1).  The  skin  is  then  punctured  and 
the  cannula  is  forced  into  the  vein.  After  the  first  joint  (A)  has  entered  vein.  Can- 
nula 1  is  withdrawn  a  distance  of  about  one-half  inch.  (This  prevents  the  vessel 
wall  from  being  injured  or  punctured  by  the  needle  after  the  vein  is  entered.) 

"With  the  thumb  now  on  the  thumb-screw  cap  of  2  the  cannula  is  forced  further 
in  until  the  second  joint  (B)  (Fig.  78)  has  entered  the  vein.  Cannula  2  is  then 
withdrawn  a  distance  of  about  one-half  inch.  (Cannula  3  alone  can  come  into  con- 
tact with  the  vessel  wall.)  Cannula  3  is  then  gently  pushed  into  the  vein  to  a  de- 
sirable length;  usually  three-quarters  to  one  inch  will  suffice. 

"Cannulas  1  and  2  are  now  withdrawn  entirely.    If  the  vein  has  been  successfully 


Fig.  79. — Lindeman's  Cannula,  Separated. 

entered,  blood  will  flow  through  the  cannula.  When  the  first  drop  appears  a  syringe 
containing  warm  saline  solution  is  immediately  attached  and  a  very  slow  flow  of 
saline  is  maintained  through  cannula. 

"(When  the  innermost  needle.  No.  1,  has  entered  the  vein,  blood  is  seen  to  trickle 
through  the  proximal  end.) 

"There  is  no  need  of  haste  at  this  stage. 

"A  cannula  is  next  inserted  in  vein  of  donor  in  a  like  manner;  an  empty  syringe 
is  attached  to  this  cannula.  Everything  is  now  in  readiness  for  the  transfusion,  and 
blood  is  withdrawn  from  donor  as  rapidly  as  possible.  When  the  syringe  is  full  the 
assistant  passes  it  to  the  operator  on  the  recipient,  who  removes  the  saline  syringe, 
attaches  the  syringe  containing  blood  and  evacuates  the  contents  gently  but  speedily 
into  the  vein. 

"One  syringeful  of  blood  is  followed  by  another  in  rapid  succession  until  the  de- 
sired quantity  of  blood  has  been  transfused. 


3U  OPEEATIONS    UPOX    BLOOD    VESSELS 

"A  little  normal  saline  is  injected  through,  cannula  of  recipient  after  every  2,  3,  4, 
or  5  syringefuls  of  blood,  depending  upon  the  speed  of  flow  from  donor.  This  keeps 
cannula  free  of  blood  and  precludes  the  possibility  of  clotting. 

"Some  25  tests  have  been  made  to  determine  the  length  of  time  required  for  blood 
to  coagulate  in  a  syringe.  This  was  found  never  less  than  6  minutes.  The  length  of 
time  required  for  the  complete  filling  and  evacuation  of  a  syringe  is  from  6  to  12 
seconds. 

"It  has  been  found  advisable  for  the  assistant  (or  third  man)  to  remove  the 
syringe  of  the  donor  as  soon  as  filled.  The  operator  can  thus  hold  the  cannula  in 
place  with  one  hand,  while  with  the  other  hand  he  may  at  once  adjust  an  empty 
syringe  into  the  cannula.    Loss  of  blood  is  thus  reduced  to  a  minimum. 

"EuLES. — (1)  Bright  polished  surfaces  of  syringe  and  cannulas  are  requisite.  (2) 
A  syringe  used  once  should  not  again  be  employed  until  thoroughly  cleansed  with 
sterile  water.  (3)  Air  must  be  avoided.  This,  however,  offers  no  difficulty.  (4) 
Tourniquet  of  recipient  must  be  removed  after  vein  is  entered  with  cannula.  (5) 
Tourniquet  remains  on  donor  throughout  operation.  (6)  Tension  of  the  tourniquet 
should  not  impede  the  arterial  flow,  but  should  be  sufficient  to  block  venous  return 
to  a  point  at  which  the  highest  venous  pressure  is  obtainable.  If  the  tension  be  too 
great  the  first  syringe  will  fill  rapidly,  the  successive  ones  will  fill  very  slowly.  If 
the  tension  be  too  little,  syringes  will  fill  slowly.  If  the  tension  be  adjusted  correctly, 
syringes  are  filled  very  rapidly.  (7)  Dexterity  and  speed  are  requisite  for  success. 
(8)  Before  beginning  a  transfusion  syringes  are  cleaned  with  hydrogen  peroxid  and 
then  washed  in  a  10  per  cent,  sodium  carbonate  solution  and  rinsed.  They  are  then 
ready  for  a  sterilization  in  alcohol.  .  .  . 

"The  time  elapsing  in  filling  and  evacuating  the  syringe  is  so  brief  that  blood 
does  not  undergo  any  alteration  from  donor  to  recipient.  For  this  reason  larger 
receptacles  for  conveying  the  blood  have  been  discarded. 

"No  lubricant  is  employed.     Cannulas  are  lined  with  a  film  coating  of  albolene. 

"Larger  syringes  with  larger  calibered  cannulas  may  be  used,  but  the  present  sizes 
have  worked  satisfactorily  and  fittings  of  syringes  and  cannulas  are  of  universal 
gauge. 

"Syringes  and  cannulas  may  be  kept  sterile  in  individual  metal  containers.  They 
are  thus  in  readiness  for  immediate  use  and  no  preparation  for  operation  is  re- 
quired. 

"When  hemolysis  occurs,  even  when  only  slight,  the  symptoms  appear  imme- 
diately, so  that  in  the  actual  performance  of  the  work  I  introduce  some  20  or  30  c.  c. 
and  then  pause  to  await  any  symptoms  of  hemolysis  appearing.  Should  none  occur 
the  transfusion  is  completed.  Should  symptoms  appear  the  cannulas  are  Avithdrawn 
and  no  harm  is  done  to  either  recipient  or  donor.  In  that  case  another  donor  is  pro- 
cured. 

"The  merits  of  this  method  may  be  summarized  as  follows:  (1)  Simplicity  for 
the  recipient.  (2)  Simplicity  for  the  donor.  (3)  No  pain,  other  than  a  skin  puncture. 
(4)  No  disturbance  of  the  recipient  or  change  of  position  is  necessary  and  the  work 
can  be  done  in  the  home  as  conveniently  as  in  a  hospital.  (5)  Any  quantity  can  be 
transfused.  (6)  The  quantity  is  definitely  known  at  the  time  of  transfusion.  (7) 
The  same  vein  may  be  used  repeatedly.  One  recipient  was  transfused  7  times  through 
the  same  vein  and  same  skin  puncture.  One  donor  was  tapped  nine  times  through 
the  same  vein  and  same  skin  puncture.  (8)  No  scar  remains  after  operation.  No 
skin  incision  is  necessary.  (9)  The  danger  from  hemolysis  is  practically  eliminated  by 
this  method.  (10)  The  facility  of  application  makes  possible  its  application  over  a 
wide  therapeutic  field.  .  .  . 

"Up  to  date  I  have  performed  137  transfusions  by  this  method.  There  were  no 
failures.  ... 


OPERATIOXS    UPOX    VEIXS  315 

"The  youngest  case  transfused  was  6  weeks  old;  weight  6  lbs.  6  oz.  The  oldest 
case  transfused  was  73  years.  In  no  case  was  there  thrombosis,  embolism  or  sepsis; 
in  no  case  was  a  skin  incision  made;  in  no  case  was  anesthesia  given;  in  no  case  was 
death  due  to  any  untoward  effects  of  transfusion. 

"Post-mortem  examinations  were  made  in  two  cases  several  weeks  after  trans- 
fusion. Yein  i^unctures  were  examined  by  Dr.  Charles  Xorris,  Director  of  Labora- 
tories of  Bellevue  and  Allied  Hospitals,  who  could  find  no  evidence  of  the  puncture. 
These  venous  puncture  wounds  heal  by  first  intention  and  no  thrombosis  occurs  at 
the  site  of  the  puncture.  .  .  . 

"In  the  total  number  of  transfusions  there  were  243  cannula  insertions  into  veins ; 
218  into  median  basilic;  25  into  external  jugular.  In  208  insertions  the  median  basilic 
vein  was  entered  on  first  puncture. 

"In  one  case  six  transfusions  were  performed  at  different  intervals  of  time,  using 
the  same  vein  through  the  same  skin  puncture  in  each  operation.  One  donor  was 
used  for  eight  transfusions  at  different  intervals  of  time;  the  cannula  was  inserted 
into  the  same  vein  through  the  same  skin  puncture  on  each  occasion.  .  .  . 

"Judgment  of  the  amount  of  blood  to  be  transfused  will  depend  upon  the  size, 
weight,  age,  physical  condition  of  the  patient,  the  type  of  disease  to  be  treated,  the 
object  to  be  gained  by  transfusion,  the  presence  of  other  complications,  and,  lastly, 
experience.  The  largest  amount  I  have  transfused  into  one  individual  in  one  sitting 
is  2,000  c.  c.     This  quantity  was  taken  from  two  donors.  .  .  . 

"The  quantity  of  blood  that  can  be  drawn  from  a  donor  varies.  The  largest 
quantity  I  have  taken  from  one  individual  in  one  sitting  is  1,400  c.  c.  The  largest 
was  5  feet  8  inches  in  height  and  weighed  ITO  lbs.  I  have  frequently  taken  900  to 
1,000  c.  c.  in  one  sitting. 

"If  the  case  be  not  one  of  infectious  disease,  two-thirds  quantity  of  the  blood  drawn 
from  donor  is  replaced  with  normal  saline  through  the  cannula  with  which  transfusion 
was  performed.     When  infection  is  present  the  same  cannula  is  not  used. 

"If  at  any  time  the  blood  pressure  in  the  donor  should  fall  so  that  blood  is  with- 
drawn with  great  difficulty,  it  is  an  indication  that  no  more  blood  can  be  spared  at 
that  time. 

"The  reaction — chill,  fever,  etc. — after  transfusion  from  a  blood  relative  in  most 
instances  is  less  than  from  an  alien.  In  three  cases  of  transfusion  from  aliens,  hemoly- 
sis occurred  from  which  patients  recovered.  (It  should  be  borne  in  mind,  however, 
that  hemolysis  can  occur  with  family  blood.) 

"Providing  the  same  donor  be  used  there  is  frequently  no  reaction  after  the 
second  and  succeeding  transfusions.  And  if  any  reaction  occurs  it  is  usually  very 
mild. 

"A  given  donor  of  alien  blood  will  cause  a  chill  and  a  temperature  in  one  patient 
and  none  in  another,  though  the  transfusions  be  done  on  the  same  day  and  both 
patients"  have  the  same  disease,  and  the  same  quantity  be  given. 

"The  chill  and  temperature  reactions  may  be  associated  with  slight  degree  of 
hemolysis  incident  to  serum  reaction.  I  have  occasionally  observed  such  hemolysis 
in  a  few  cases  evident  only  by  a  slight  jaundice  tint  disappearing  within  24  hours.  In 
such  case  in  the  succeeding  transfusion,  the  same  donor  being  used,  this  tint  is  absent 
or  less. 

"In  the  actual  performance  of  the  work  I  introduce  a  small  quantity  of  blood  and 
then  pause  for  a  short  period  of  time  before  continuing  transfusion.  Opportunity  is 
thus  afforded  for  observing  the  compatibility  of  the  blood  introduced. 

"Should  an  undesirable  reaction  ever  occur  indicative  of  incompatibility,  trans- 
fusion is  discontinued;  no  harm  is  done  and  another  donor  is  procured.  Danger  from 
hemolysis  is  thus  eliminated." 


316  OPERATIONS    UPON    BLOOD    VESSELS 

McGEATH'S  METHOD. — McGrath  has  recently  described  a  modification  of 
Aveling's  method,  in  which  he  uses  a  30  c.  c.  rubber  bulb  having  two  long 
polar  processes,  or  cannulse,  of  suitable  size  to  enter  the  veins.  The  latter 
are  exposed  in  the  usual  manner  and  the  tips  of  the  processes  are  inserted  into 
them,  after  filling  the  bulb  with  salt  solution,  and  held  by  ligatures.  Alternate 
filling  and  emptying  of  the  bulb  by  compression  and  release  from  the  donor 
into  the  recipient  transfer  the  desired  amount  of  blood.  The  apparatus  is 
made  without  joints.  No  anticoagulant  is  used  and  the  method  has  proved 
successful  in  experimental  work. 

SATTEELEE  AND  HOOKEE'S  METHOD. — Satterlee  and  Hooker  have  re- 
cently published  an  account  of  a  method  which  appears  to  be  an  improvement 
on  Curtis  and  David's.     See  Volume  I,  Chapter  IX. 

Choice  of  Methods.^ — No  absolute  decision  can  at  present  be  made  as  to 
which  is  the  best  method  of  transfusion.  Unquestionably  the  direct  method 
has  received  more  attention  and  has  been  practiced  a  greater  number  of  times 
in  the  past  10  years  than  has  the  indirect  method.  The  possibilities  of  the 
latter,  however,  are  at  present  being  more  thoroughly  investigated,  and  it  is 
probable  that  the  next  decade  will  see  a  reversal  of  the  proportion  of  direct  to 
indirect  transfusion. 

Curtis  and  David,  in  a  recent  communication,  summarize  their  objections 
to  the  direct  method  as  follows : 

"The  operation  requires  delicate  technic  such  as  is  possessed  only  by  those 
who  have  had  experience  in  blood-vessel  surgery.  Considerable  time  is  con- 
sumed in  performing  anastomosis  of  the  vessels.  The  rate  of  flow  and  the 
amount  of  blood  transfused  are  not  measurable.  The  flow  of  blood  sometimes 
ceases  before  the  desired  amount  has  been  transfused,  even  though  the  oper- 
ative technic  is  excellent.  Movement  of  either  donor  or  recipient  may  tear 
the  vessels  apart  at  their  point  of  union  in  spite  of  watchfulness  on  the  part 
of  the  operators.  In  infectious  patients  there  is  always  danger  of  transfer  of 
infection  from  the  recipient  to  the  donor.  This  is  most  liable  to  occur  through 
the  rubbing  of  the  raw  surfaces  which  are  held  or  bound  together  during  the 
entire  procedure." 

The  third  objection  of  this  series  is  the  only  one  that  can  be  held  to  apply 
against  the  direct  method  of  transfusion  by  glass  tubes  as  originated  by 
Brewer  and  modified  by  Eauntleroy.  The  others  apply  no  more  to  this  method 
than  to  Curtis  and  David's  own. 

Eisley  and  Irving  have  (in  1911-12)  carefully  and  critically  tested  Crile's 
cannula,  Soresi's  cannula,  Frank's  (dog's  carotid),  and  Hartwell's  (simple 
invagination  of  artery  into  vein)  methods.  Brewer's  tubes  and  Curtis  and 
David's  syringe  and  receptacle  with  a  view  of  settling  which  is  at  present  the 
most  generally  useful  method  of  transfusion.  They  say:  "In  so  far  as 
purely  mechanical  metal  devices  go,  this  admirable  little  adjustable  cannula 
(Elsberg's)  is  still  the  best."  They  call  the  paraffined  glass  tubes  "far  ahead 
of  any  of  the  other  more  complicated  devices  proposed,  but  also  by  far  the 


OPEEATIOXS    UPOK    VEINS  317 

most  satisfactory  for  all  round  transfusion  work,   arterj-to-vein,  or  vein-to- 
vein,  adult  or  infant,  and  for  skilled  or  unskilled  operators." 

They  also  speak  favorably  of  Curtis  and  David's  method. 

Just  at  present,  then,  it  would  appear  that  direct  transfusion  by  the  par- 
affin-lined glass  tube  is  the  most  generally  available  and  simplest,  but  it  lacks 
the  advantage  possessed  by  the  indirect  methods  of  accurately  measuring  the 
amount  of  blood  transfused.  In  as  much,  howevej-,  as  the  effect  upon  the  re- 
cipient, as  observed  in  his  general  appearance,  raised  hemoglobin  index  and 
increased  blood  pressure  and  in  the  reduction  in  rate  and  the  improvement  in 
quality  of  his  pulse  is  the  real  indication  of  the  effect  of  transfusion,  rather 
than  the  accurate  measurement  of  the  amount  of  blood  passed,  this  lack  cannot 
be  considered  of  the  first  importance. 

If,  however,  the  indirect  method  with  syringe,  as  practiced  by  Moritz, 
Lindeman,  Cooley  and  Vaughan,  and  others,  or  with  the  paraffin-lined  glass 
receptacle  of  Curtis  and  David  and  Satterlee  and  Hooker,  proves  as  safe  as 
the  direct  method,  it  will  doubtless  become  the  method  of  choice ;  and  in  this 
city  it  is  probably  more  used  now  than  the  direct  method.  If  the  direct 
method  be  used  there  is  still  some  question  as  between  the  artery-to-vein  and 
the  vein-to-vein  practice  of  it.  Dorrance  and  Ginsberg  state  the  advantages 
of  artery-to-vein  procedure  as:  giving  sufficient  blood  pressure  to  introduce 
blood  quickly  from  donor  into  recipient;  that  blood  from  artery  is  richer  in 
oxygen  than  that  of  vein.  They  believe,  however,  that  vein-to-vein  procedure  is 
simpler  and  safer  and  recommend  its  use. 

Lilienthal  states  the  advantages  of  the  vein-to-vein  method  as  follows: 
The  dissection  does  not  open  the  fascial  planes  of  the  wrist  to  possible  infec- 
tion. The  radial  pulse  is  not  interfered  with.  The  dissection  and  manipula- 
tion of  the  vein  is  easier  than  that  of  the  artery.  The  donor's  vein  generally 
used  is  larger  than  the  radial  artery.  The  vein  is  less  susceptible  to  external 
influence  (for  example,  contraction  of  artery  and  resulting  slow,  or  no,  flow). 
The  flow  is  rapid  and  steady. 

Elsberg  also  (personal  communication)  prefers  the  vein-to-vein  procedure. 
Among  the  difficulties  of  the  operation  may  be  mentioned:  refusal  of  radial 
artery  to  bleed;  inability  to  find  sufficiently  large  vein  in.  arm;  clotting  of 
blood  in  cannula;  piercing  vein. 

Peck  mentions  an  instance  where  the  donor's  radial  artery  absolutely  i-e- 
fused  to  bleed. 

Peck,  Lilienthal,  Warren,  and  others  have  mentioned  the  difficulty  of  find- 
ing a  suitable  vein  in  the  arm  of  the  recipient.  In  a  few  cases  this  resulted  in  fail- 
ure of  the  operation,  as  the  patient  would  not  allow  any  other  vein  to  be  used. 

Peck,  Lilienthal,  Bernheim,  and  others  mention  the  occurrence  of  clotting 
in  the  cannula,  or  at  the  point  of  anastomosis. 

Warren  and  others  mention  the  possibility  of  thrusting  the  point  of  the 
needle,  or  trocar,  through  the  opposite  wall  of  the  vein  while  attempting  to 
introduce  it  into  the  lumen. 


318  OPERATIOI^S    UPO:^    BLOOD    VESSELS 

Dangers  of  Transfusion. — Among  the  possible  dangers  of  the  operation 
should  be  mentioned:  transmission  of  disease  from  donor  to  recipient;  trans- 
mission of  disease  from  recipient  to  donor ;  hemolysis ;  agglutination ;  acute 
dilatation  of  the  heart ;  air  embolism ;  blood  embolism ;  suction  changing  gas- 
eous tension  of  blood ;  laking  red  cells  and  setting  free  toxic  substances, 

TEANSMISSION  OF  DISEASE  FEOM  DONOE  TO  EECIPIENT  (Syphilis,  Gon- 
orrhea, Malaria,  etc.). — This  can  be  entirely  avoided  by  a  thorough  prelimi- 
nary examination  of  the  donor. 

TEANSMISSION  OF  DISEASE  FEOM  EECIPIENT  TO  DONOE  (Typhoid, 
Septicemia,  etc.). — This  can  be  avoided  by  using  an  immune  donor,  or  by 
avoiding  any  actual  contact  between  donor  and  recipient.  (Brewer's  tube  or 
indirect  method.) 

HEMOLYSIS. — Hemolysis  is  regarded  as  a  real  and  ever-present  danger  by 
many  surgeons,  but  Bernheim  remarks:  "The  danger  of  hemolysis  following 
transfusion  has  always  been  vastly  overrated  and  unwarrantably  feared.  In  a 
rather  large  series  of  transfusion,  done  for  the  relief  of  many  and  varied  con- 
ditions, I  have  never  seen  it  occur,  and  I  know  of  but  one  authentic  instance 
where  it  complicated  matters. 

"It  must  be  remembered  that  hemolytic  tests,  even  at  best,  are  not  en- 
tirely conclusive  and  do  not  absolutely  protect  against  hemolysis.  The  blood 
of  one  individual  may  hemolyze  that  of  another  in  the  test  tube,  but  not  in  the 
body  after  transfusion ;  and,  vice  versa,  the  laboratory  tests  may  pronounce 
an  individual  a  suitable  donor,  and  yet  hemolysis  may  occur  after  transfusion." 

On  the  other  hand,  Elsberg,  Lilienthal,  Peck,  Lindeman,  and  others  em- 
phasize the  extreme  importance  of  it.  Elsberg  has  done  2  successful  cases 
without  preliminary  test  in  emergency  cases.  Peck  mentions  a  case  in  which 
it  was  impossible  to  get  a  hemolysis  test  beforehand.  The  patient  was  trans- 
fused by  the  Lindeman  technic  with  33  syringefuls.  She  died  within  48 
hours  with  signs  of  obscure  blood  changes. 

Lindeman  mentions  one  case  where  the  laboratory  reported  hemolysis  test 
negative,  but  hemolysis  was  noted  after  75  c.  c.  had  been  given.  Transfusion 
was  stopped,  and  another  serologist  reported  hemolysis  test:  slight  hemolysis 
of  donor's  cells  with  recipient's  seruni. 

Another  case:  no  hemolysis  in  first  transfusion.  Second  transfusion  5 
days  later,  with  same  donor.  No  hemolysis  test  done.  Hemolysis  showed  at 
transfusion,  however,  and  test  then  made  showed  hemolysis  of  donor's  cells 
with  recipient's  serum. 

Another  case :  laboratory  report  negative ;  yet  hemolysis  occurred  at  trans- 
fusion ;  no  opportunity  to  check  up  laboratory  report ;  all  3  cases  recovered. 

AGGLUTINATION. — Agglutination  of  red  cells  is  apparently  less  to  be 
feared  than  hemolysis;  but  Lilienthal  emphasizes  the  importance  of  making 
the  test  beforehand.  Warren  mentions  a  case  of  pernicious  anemia  in  which 
he  failed  in  an  attempt  at  transfusion  by  the  Lindeman  method  on  account  of 
the  small  size  of  vein  in  the  arm.    Two  days  later  Lindeman  himself  successfully 


OPERATIONS    UPON    VEINS  319 

transfused  this  case  through  the  external  jugular.  The  patient  died  within  48 
hours.  In  this  case  there  was  a  very  slight  positive  agglutination  reaction 
obtained  beforehand,  although  the  hemolysis  test  was  negative. 

ACUTE  DILATATION  OF  THE  HEAET. — Acute  dilatation  of  the  heart  dur- 
ing transfusion  is  another  rare  accident.  Crile  mentions  several  instances  in 
his  book,  none  of  which  were  fatal.  It  has  been  difficult  to  find  any  positive 
evidence  of  fatal  cases.  Lilientlial  and  Peck  had  not  observed  the  accident  in 
their  practice.  Elsberg  mentions  one  case  who  died  shortly  after  the  trans- 
fusion by  the  direct  artery-to-vein  method.  He  believes  that  they  gave  her  too 
much  blood.     She  was  a  woman  suffering  from  malignant  endocarditis. 

AIR  EMBOLISM. — I  have  been  unable  to  discover  any  deaths  thought  to  be 
referable  to  the  entrance  of  air  into  the  veins  at  transfusion.  Theoretically 
one  would  expect  it  to  be  a  fairly  common  accident  in  the  syringe  class  of 
operations.  But,  as  a  matter  of  fact,  it  is  highly  probable  that  small  amounts 
of  air,  so  introduced,  do  not  give  rise  to  untoward  symptoms. 

BLOOD  EMBOLISM. — No  positive  evidence  is  obtainable  of  any  fatalities 
due  to  this  cause  following  transfusion,  but  Warren  speaks  of  one  case  of  per- 
nicious anemia  that  died  of  pneumonia  within  a  week  following  transfusion  by 
the  Lindeman  method.  Warren  thought  the  pneumonia  might  be  attributable 
to  pulmonary  infarction. 

ALTERATION  OF  THE  GASEOUS  TENSION  OF  THE  BLOOD. — Alteration  of 
the  gaseous  tension  of  the  blood  due  to  suction,  and  laking  of  the  red  cells 
with  setting  free  of  toxic  substances,  from  contact  with  syringe  or  cannula 
walls,  have  been  mentioned  by  Warren  and  Connell  as  possible  dangers  in  those 
methods  that  use  syringe  suction  and  employ  no  paraffin  to  line  the  cannula. 
No  definite  evidence  is  obtainable  of  the  reality  of  such  dangers. 

Intravenous  Injection 

Intravenous  injection  for  purposes  of  local  or  general  anesthesia  is  de- 
scribed in  the  chapter  on  Anesthesia. 

Venesection 

Venesection  is  an  operation  little  used  at  present  except  when  it  is  desired 
rapidly  to  lower  blood  pressure,  as  in  certain  cases  of  cerebral  hemorrhage, 
uremic  coma,  etc. ;  or  where  it  is  desired  to  remove  a  certain  amount  of  toxic 
or  deteriorated  blood  before  replacing  it  with  healthy  blood  or  saline  solution, 
as  in  illuminating  gas,  carbon  monoxid  poisoning,  etc. 

The  vein  selected  may  be  the  external  jugular,  the  internal  saphenous,  or, 
more  commonly,  the  median  basilic  or  cephalic.  The  latter  is  perhaps  pref- 
erable on  account  of  its  greater  distance  from  the  brachial  artery  and  its 
freedom  from  nearby  cutaneous  nerves.  A  constrictor  is  applied  at  mid  arm 
tight  enough  to  distend  the  superficial  veins.     The  skin  over  the  anterior  sur- 


320  operatio:nts  upon  blood  vessels 

face  of  the  elbow  is  then  painted  with  iodin,  which  is  allowed  to  dry  and  then 
washed  off  with  alcohol.  The  vein  is  then  steadied  between  the  thumb  and  fore- 
finger of  the  left  hand  while  a  sharp  scalpel  divides  it  transversely,  together 
with  the  overlying  skin,  to  about  one-half  of  its  diameter.  Local  anesthesia 
may,  of  course,  be  used  if  desired.  The  flow  of  blood  may  be  increased  by  caus- 
ing the  patient  to  grasp  a  stick  tightly.  It  may  be  lessened  by  digital  pressure 
over  the  vein.  The  amount  of  blood  removed  usually  varies  from  8  to  16 
ounces.  When  sufficient  blood  has  been  removed  the  flow  of  blood  is  arrested 
by  removing  the  constrictor,  and  strapping  a  pledget  of  sterile  gauze  over  the 
phlebotomy  wound. 

OPERATIONS    TO    REMOVE    THE    CAUSE    OF    CIRCULATORY    DISTURBANCE 
DUE    TO    VARICOSE    VEINS 

Binnie  says:  "The  principle  of  treatment  of  varicose  veins  is  the  trans- 
ference of  the  venous  circulation  from  the  superficial  to  the  deep  veins,  .^but 
before  attempting  to  do  this  it  must  be  shown  that  there  is  neither  thrombosis 
of  the  deep  veins  nor  marked  obstruction  to  the  return  of  the  blood  through 
them. 

"Mayo,  in  doubtful  cases,  applies  an  elastic  support  to  the  limb  for  a  week ; 
if  this  gives  comfort  it  is  fairly  evident  that  the  deep  vessels  are  capable  of 
doing  their  duty." 

Methods  of  Treatment 

The  methods  usually  described  are:  injection,  ligation,  excision,  incision, 
suture. 

The  treatment  of  varicose  veins  by  injection,  acupressure,  and  subcutane- 
ous ligation  is  antiquated,  and  should  not  be  employed.  Incision,  excision, 
and  suture  are  the  methods  commonest  at  present. 

Treatment  by  Excision. — Excision  is  the  method  most  in  use.  The  dilated 
veins  are  marked  upon  the  skin,  while  the  patient  is  in  the  standing  position, 
with  tr.  iodin,  silver  nitrate,  or  some  other  stain ;  or  scratches  are  made  in  the 
skin  over  them  with  a  sharp  scalpel.  At  the  same  time  a  test  is  made  as  to  the 
free  communication  of  the  varices  with  the  deeper  veins.  With  the  patient 
recumbent,  the  surgeon  places  his  finger  upon  the  saphenous  vein  just  below 
its  entrance  into  the  femoral  and  causes  the  patient  to  stand  up.  If,  while  the 
varices  are  thus  relieved  of  the  weight  of  the  superimposed  blood,  they  still 
dilate  from  below  the  Trendelenburg  operation  alone  is  useless.  It  may,  how- 
ever, be  used  in  addition  to  the  excision  in  continuity. 

After  a  very  careful  preparation  of  the  operative  field  an  incision  is 
marked  over  the  dilated  vein.  If  the  vein  is  broadly  adherent  to  the  skin  it  is 
often  easier  to  excise  a  portion  of  the  latter  with  it.  Otherwise,  the  incision 
is  deepened  carefully  just  through  the  skin  and  flaps  are  raised  on  each  side 
of  the  incision  by  thrusting  blunt,  scissors  beneath  the  skin  and  forcing  the 


OPEEATIOl^S    UPOIT    VEmS  321 

blades  apart  This,  added  to  a  little  necessary  sharp  dissection,  will  expose  a 
considerable  area  of  vein  which  is  ligated  together  with  its  tributaries,  above 
and  below,  and  excised  for  a  distance  of  several  inches.  All  bleeding  is  then 
stopped,  the  wound  carefully  cleansed,  and  its  edges  united  with  fine  silk,  con- 
tinuous suture;  or,  perhaps  better,  by  interrupted  sutures  alternating  with 
narrow  strips  of  sterile  adhesive.  This  procedure  may  be  repeated  until  the 
continuity  of  the  dilated  venous  channel  has  been  interrupted  at  3  or  4  levels. 
Sometimes  the  dilated  trunk  vein  and  its  tributaries  arrange  themselves  in  a 
sort  of  nest  or  plexus  2  or  3  inches  in  diameter,  especially  just  below  the  knee, 
in  front,  internal,  or  behind.  It  is  more  satisfactory  in  such  cases  to  excise  a 
considerable  area  of  skin,  together  with  the  whole  mass  of  dilated  tortuous 
veins  and  their  surrounding  fat,  right  down  to  the  deep  fascia.  The  defect 
may  then  be  closed  by  loosening  superficial  fascia  around  the  edges  of  the 
wound  from  the  deep  fascia  and  drawing  the  wound  edges  together  with  sev- 
eral deep  tension  sutures  of  silk-worm  gait.  Proper  coaptation  of  the  margins 
then  follows,  with  silk,  as  before.  Better  approximation  is  secured  in  this 
way,  and  the  tendency  of  thin,  extensive  flaps  to  slough  is  avoided. 

Dry  dressings  are  applied,  the  limb  is  elevated  and  closely  bandaged  from 
toes  to  groin.  A  well-padded  posterior  splint  of  wood,  or  a  more  comfortable 
one  of  moulded  plaster,  is  then  added,  and  the  patient  kept  in  bed  for  at  least 
ten  days,  or  preferably  two  weeks,  as  the  experience  of  the  Mayo  Clinic  has 
shown  that  practically  all  the  cases  of  embolism  complicating  this  operation 
have  occurred  within  14  days  after  operation.  If  the  varicosities  have  been 
extensive  the  patient  should  be  recommended  to  wear  a  woven  bandage  of  the 
''Ideal"  type  or  a  well-fitting  elastic  stocking  for  a  few  weeks  after  the  opera- 
tion. 

If  the  varicosities  are  the  result  of  weight  pressure  from  the  superimposed 
column  of  blood,  the  veins  do  not  distend  when  the  limb  is  allowed  to  hang 
down  while  pressure  is  made  upon  the  upper  part  of  the  saphenous  vein  by  the 
examiner's  finger,  which  has  been  previously  placed  there  with  the  limb  in 
the  horizontal  position. 

TEENDELENBUEG 'S  OPEKATION. — ^In  such  cases  Trendelenburg's  opera- 
tion may  be  sufficient.  It  consists  of  the  excision,  between  ligatures,  of  an 
inch  or  two  of  the  saphenous  vein  at  the  upper  part  of  the  thigh.  A  rubber 
constrictor  placed  around  the  limb  near  the  groin  may  be  used  to  dilate  the 
vein  and  make  its  localization  easier,  and  in  fat  patients  a  transverse  incision 
may  discover  the  vein  more  readily  than  a  longitudinal  one. 

MAYO'S  OPEEATION. — Mayo  devised  a  dissector  with  accompanying  for- 
ceps to  facilitate  the  excision  of  the  varicose  vein  through  small  skin  incisions. 
It  is  exceedingly  efficient  if  the  vein  is  thick-walled  and  not  too  tortuous,  but 
is  apt  to  tear  thin-walled,  tortuous  vessels.  It  is  used  as  follows:  expose  and 
isolate  about  1  inch  of  the  saphenous  vein  near  the  saphenous  opening.  Divide 
it  between  double  ligatures  and  thread  the  distal  end  through  the  eye  of  the 

probe  dissector  (Fig.  80a)  and  put  an  artery  clamp  on  it.     Hold  the  clamp 

22 


323 


OPEEATIOKS    UPON   BLOOD    VESSELS 


in  one  hand  and  push  the  dissector  downward  beneath  the  skin,  guided  by  the 
vein,  to  a  point  near  the  knee.  It  may  be  advantageous  to  have  an  assistant 
press  the  skin  upward  against  the  advancing  dissector.  If  its  progress  is  ob- 
structed by  adhesions  around  the  vein  pass  the  adhesion  forceps  (Fig.  80b) 
over  the  vein  down  to  the  point  of  obstruction.  Tear  the  adhesions  by  gently 
opening  the  blades  of  the  forceps  and  then  proceed  with  the  dissection.  When 
the  eye  of  the  dissector  has  reached  a  point  near  the  knee  make  a  small  in- 
cision over  it,  push  it  out  through  the  skin,  clamp  the  vein,  and  withdraw  the 
dissector.     Eethread  the  vein  in  the  dissector,  reintroduce  the  latter  through 


Fig.  80. — a,  Mato's  Dissectoe  for  Varicose  Veins;  b,  Mayo's  Adhesion  Forceps  for  Varicose 

Veins. 


the  lower  incision,  and  continue  the  dissection  downward.  Remove  as  many 
other  veins  as  is  deemed  necessary  in  a  similar  way.  Binnie  calls  special 
attention  to  the  advisability  of  making  the  dissection  from  above  downward 
to  avoid  the  danger  of  detaching  thrombi  and  setting  them  free  in  the  circula- 
tion. The  bleeding  from  the  tributaries  that  are  torn  off  can  readily  be  stopped 
by  pressure  with  gauze  pads.  The  wounds  are  closed  by  suture ;  dry  dressings 
are  applied  and  a  snug  bandage,  applied  from  below  upward  (toes  to  groin), 
with  a  posterior  splint,  is  added. 

EXCISION  BY  INVEESION.— ]\Iamourian  elevates  the  limb,  exposes  and  di- 
vides the  internal  saphenous  vein  near  the  saphenous  opening,  ligates  the 
proximal  end,  and  clamps  the  distal.  Traction  on  the  clamp  indicates  the 
position  of  the  vein  near  the  knee,  and  it  is  exposed  and  divided  again  through 
a  small  incision  at  this  point.  The  distal  end  is  clamped  and  a  long  probe  is 
passed,  eye  first,  into  the  proximal  end  upward  and  out  of  the  upper  incision. 
The  upper  end  of  the  vein  segment  is  fastened  to  it  by  a  silk  suture  that 
penetrates  the  vein  wall  through  and  through  and  is  tied  through  the  end  of 
the  probe.     Strong  traction  on  the  lower  end  of  the  probe  extracts  the  segment 


OPERATIOIs^S    UPOI^   VEII^S 


323 


of  vein,  turning  it  outside  in.     Mamourian  says  a  gnm  elastic  catheter  may  be 

used  instead  of  a  probe,  if  the  veins  are  very  tortuous.     This  method  is  not 

applicable  to  general  or  cirsoid  varicosities. 

BABCOCK'S  OPEKATION. — Babcock  devised  a  long,   pliable  probe  with  a 

small  olivary  tip  at  one  end  and  a  larger  oval  tip  at  the  other,  cupped  under- 
neath so  as  to  catch  the  cut  end  of  the  vein.     It  is  used 

as  follows:  expose  and  isolate  about  1  inch  of  vein  at 

the  upper  end  of  the  segment  whose  removal  is  intended. 

Grasping  it  in  a  hemostat,  make  a  small  incision  into 

the  wall  and  introduce  the  small  end  of  the  probe.    Pass 

it  downward  within  the  vein,  as  far  as  possible,  and  tie 

the  upper  end  of  the  segment  tightly  around  it  just 

below  the  large  end.     Cut  the  vein  between  this  and  the 

hemostat  and  replace  the  latter  by  a  ligature.     Make  a 

small  incision  through  the  skin,  fascia,  and  vein  wall 

upon  the  small  ends  of  the  probe.     Grasp  this  and  make 

traction  combined  with  a  series  of  short  jerks.      The 

vein  comes  away,  pleated  in  a  small  mass  against  the 

cupped  surface  of  the  larger  tip;  hemostasis;  wound 

closed ;  .dressings ;  bandage,  and  splint  as  usual. 

FOSTEE'S  METHOD. — Foster  in  a  similar  way  uses  2 

feet  of  jSTo.  4  copper  wire,  bent  at  one  end  into  a  loop, 

or  neck,  around  which  the  cut  end  of  the  vein  to  be 

stripped  out  is  tied. 

Treatment     Tjy    Incision CIECULAE    incision. — 

Schede    has    advocated  a  complete    circular    incision 

dividing  all  tissues  down  to  the  deep  fascia  in  the  upper 

third  of  the  leg,  double  ligating  each  vein  as  it  is  cut. 

Von  Wenzel  adds  a  second  similar  circular  incision  at 

the  junction  of  the  lower  and  middle  third  of  the  thigh. 

SPIEAL  INCISION. — Reindfleisch  and  Friedel  divide  the  internal  saphenous 
vein  between  ligatures  high  up  in  the  thigh ;  mark  a  spiral  with  5  to  8  turns 
around  the  leg ;  deepen  this  by  incision  to  the  deep  fascia,  catching  and  ligating 
the  divided  vessels;  pack  the  wound  to  hold  the  edges  of  the  spiral  apart  and 
force  it  to  heal  by  granulation  and  epidermization.  This  leaves  a  deep  spiral 
gutter  in  the  leg  (Fig.  81).  Where  ulcers  exist  they  include  them,  between 
turns  of  the  spiral,  joining  these  by  vertical  incisions  on  each  side  of  the 
ulcer. 

Kayser  reported  18  cases  done  by  this  method,  all  of  the  most  severe  type. 
He  declared  that  the  size  of  the  leg  diminished  and  remained  smaller,  existing 
ulcers  were  healed,  there  were  no  sensory  disturbances  of  the  skin,  and  his 
patients  were  well  satisfied  with  the  results.  He  makes  6  to  12  spiral  turns 
according  to  extent  of  varicosities,  beginning  on  dorsum  of  foot,  with  3  parallel 
incisions  on  dorsum,  which,  he  says,  prevents  edema ;  and  if  ulcers  are  large  he 


Fig.  81. — Fhiedel's  Spi- 
EAL  Operation  for 
Vaeicose  Veins. 


324 


OPEEATIO^S    UPON^    BLOOD    VESSELS 


carries  the  incisions  through  them.     He  keeps  the  patient  in  bed  4  weeks  after 
operation. 

Geinitz,  reporting  the  late  results  of  this  operation  performed  for  varices 
at  Garre's  Clinic,  says  they  are  surprisingly  good.  The  ulcer  only  recurred  in 
one  case.  He  recommends  it  highly  for  diffuse  varices  and  cases  where 
simpler  methods  have  failed. 

Treatment  by  Suture. — ^DELBET'S  OPEEATION. — Delbet,  in  1906,  suggested 
and  carried  out  by  suture  a  re -implantation  of  the  saphenous  vein  into  the 

femoral  10  or  12  cm.  below  its  original 
entrance.  His  object  was  to  cure  varices 
by  relieving  them  of  the  weight  of  the 
superimposed  blood  column  through  the 
interposition  of  one  or  more  sets  of  com- 
petent valves.  He  reported  8  cases,  and 
Hesse  and  Schaack  collected  48  cases  in 
all.  There  was  1  death  out  of  Hesse  and 
Schaack's  23  own  cases,  and  they  called 
the  other  22  cured. 

HESSE  AND  SCHAACK'S  OPEEATION. 
— Hesse  and  Schaack  operated  as  fol- 
lows :  An  incision  12  to  15  cm.  long  was 
made  through  skin  and  superficial  fascia 
at  Scarpa's  triangle  in  the  direction  of 
the  internal  saphenous.  This  vein  was 
isolated,  and  all  but  the  largest  branches 
were  ligated.  They  then  exposed  and 
freed  the  femoral  vein  for  a  sufficient  dis- 
tance, ligated  the  saphenous  at  its  en- 
trance into  the  femoral  vein,  put  a  tem- 
porary hemostat  on  it  a  little  below,  and 
divided  the  vein  between  ligature  and 
serrefine.  They  then  reimplanted  the 
distal  cut  end  of  the  saphenous  into  the 
femoral  vein  at  least  10  cm.  distal  to  its  original  entrance,  using  a  traction 
suture  at  the  upper  and  lower  ends  of  the  anastomosis,  and  then  completing  it 
by  a  continuous  suture  (Fig.  2).  After  operation  no  immediate  improvement 
was  apparent,  but  soon  the  Trendelenburg's  symptom  disappeared.  In  21  of 
the  23  cases  the  patency  of  the  anastomosis  was  established. 

JEGEE'S  METHOD. — Jeger  suggests  the  advisability  of  minimizing  the  dan- 
ger of  thrombosis  by  employing  for  the  anastomosis  his  own  method  of  end-to- 
side  implantation  of  veins  which  approximates  the  endothelial  surfaces  very 
exactly. 

COENEN'S  METHOD. — Coenen  originated  an  operation  similar  to  Delbet's 
for  relief  of  varices  of  the  external  saphenous.  He  ligated  and  divided  the  upper 


Fig.    82.  —  Delbet's    Operation   After 
Hesse  and  Schaack. 


OPEKATIONS    UPON^    VEINS  325 

part  of  the  small  saphenous  and  united  its  distal  end  by  circular  suture  to  the 
central  end  of  the  ligated  and  divided  posterior  tibial.  His  end  results  are  not 
available,  but  he  saw  the  tibial  vein  fill  with  blood  from  below  upward,  indi- 
cating that  he  had  accomplished  his  object  of  affording  another  exit  for  the 
blood  in  the  saphenous  system, 

KATZENSTEIN'S  METHOD. — Katzenstein,  reasoning  that  the  varicosities  of 
the  saphenous  system  are  due  to  lack  of  muscular  support,  originated  a  pro- 
cedure in  which  he  frees  the  internal  saphenous  as  widely  as  possible,  lays  it 
on  the  sartorious  muscle,  and  builds  a  muscular  canal  for  it  by  suturing  the 
latter  around  it.     His  results  are  said  to  be  good. 

Choice  of  Method. 

The  choice  of  method  depends  largely  upon  the  extent  and  type  of  the 
varicosities.  Subcutaneous  removal  by  Mayo's  dissector,  Babcock's  probe,  or 
the  inversion  method  of  Mamourian  works  very  well  if  the  veins  are  thick- 
walled  and  not  very  tortuous  and  adherent.  But  thin-walled  veins,  tortuous 
and  adherent,  are  best  removed  by  open  excision.  Where  the  skin  is  thinned 
out  and  the  subcutaneous  fat  that  normally  lies  between  it  and  the  vein  has 
been  replaced  by  fibrous  tissue  resulting  from  chronic  periphlebitis  it  is  more 
satisfactory  to  remove  the  skin  and  veins  en  masse  down  to  the  deep  fascia, 
freeing  the  flaps  sufficiently  to  bring  them  together  without  tension.  The 
high  ligation  in  the  thigh  may  properly  be  added  to  any  of  these  procedures 
where  Trendelenburg's  symptom  is  present ;  and,  in  mild  cases,  it  alone  may  be 
sufficient.  The  reimplantation  of  the  saphenous  is  suitable  only  for  cases  ex- 
hibiting Trendelenburg's  sjnmptom;  and,  inasmuch  as  the  other  simpler  opera- 
tions are  safer  and  more  satisfactory  in  almost  all  cases,  if  properly  and  thor- 
oughly carried  out,  the  saphenofemoral  anastomosis  by  suture  seems  hardly 
justifiable.  It  has  been  practiced  little,  if  at  all,  in  this  country.  The  circular 
incisions  of  Schede  and  Von  Wenzel  do  not  appeal  to  me  as  being  much  more 
rational  than  the  wearing  of  one  or  two  tight,  circular  garters ;  but  the  com- 
plete spiral  of  Rindfleisch  and  Friedel  has  given  good  results  in  properly 
selected  cases,  and  should  be  reserved  for  those  Avhere  there  are  extensive 
varicosities  with  marked  periphlebitis,  varicose  ulcers,  and  edema. 

The  operation  of  excision  is  simple  but  tedious  and,  with  the  exception  of 
the  suture  anastomosis,  all  the  other  methods  are  easily  performed.  The  only 
dangers  that  are  to  be  feared  are  infection,  which,  of  course,  is  more  liable  to 
occur  in  ill-nourished  tissue,  such  as  that  in  the  varicotic  area ;  and  embolism, 
which  is  fortunately  very  rare.  A  certain  amount  of  necrosis  of  the  edge  of 
the  wound  margins  is  not  infrequently  seen,  due  probably  to  the  destruction  of 
their  blood  supply  in  imdermining  them. 

Goerlich  reported  2  cases  of  pulmonary  embolism  in  147  operations  done 
by  Trendelenburg's  method,  and  collected  in  all  8  cases^  following  various 
operations  for  varicose  veins. 


326  OPEKATIONS    UPON    BLOOD    VESSELS 

Wilson  says  that  (1)  from  1  to  3  per  cent,  of  all  cases  of  blood  vessel  opera- 
tions give  more  or  less  distinct  clinical  evidence  of  emboli,  over  YO  per  cent,  of 
which  are  pulmonary;  (2)  probably  about  10  per  cent,  of  cases  of  postoperative 
emboli  are  fatal;  (3)  autopsy  shows  about  80  per  cent,  of  these  emboli  to  rise 
from  venous  thrombosis;  (4)  in  over  12  years  at  St.  Mary's  Hospital  only  1 
fatal  case  of  embolism  followed  phlebectomy  of  varicose  veins  of  leg;  (5)  in 
1,3Y2  operations  on  blood  vessels  during  the  same  period  there  were  only  2 
deaths  from  embolism.     One  of  these  was  cerebral,  the  other  pulmonary. 

Results  of  Treatment 

Matas  quotes  Goerlich,  who  wrote  that  in  1,425  cases  reported  by  42 
operators  he  found  65  per  cent,  to  85  per  cent,  of  cures  after  ligation  of  the 
internal  saphenous. 

Miller  reports  79  per  cent,  of  cures  by  Trendelenburg's  operation  in  4l 
cases  at  Halsted's  Clinic. 

Perthes  reported  Y8  per  cent,  of  cures  by  Trendelenburg's  operation  in 
Trendelenburg's  Clinic. 

The  Schede  operation  in  Johns  Hopkins  Clinic  gave  33  per  cent,  of  cures 
in  19  cases. 

"Relapse,"  says  Matas,  "is  more  likely  to  follow  the  single  linear  division 
of  veins  than  the  more  thorough  extirpation."  ISTevertheless,  the  secondary 
dilatation  of  small  superficial  tributaries  of  the  extirpated  veins,  the  re- 
establishment  of  direct  end-to-end  commimication  through  the  scar,  especially 
after  ligation,  and  the  regeneration  of  veins  will  cause  a  certain  percentage  of 
relapses  even  after  extensive  resection  of  veins. 

Jeannel  is  quoted  by  Binnie  as  taking  the  high  conception  of  "cured"  to 
mean  the  restoration  to  the  patient  of  a  "healthy,  vigorous,  painless  limb."  He 
says  that  out  of  697  limbs  operated  on  by  (1)  Trendelenburg's  operation,  or 
its  variants,  56  per  cent,  were  cured;  (2)  out  of  23  limbs  in  which  was  done 
resection  of  the  whole  femoral  part  of  the  internal  saphenous,  52  per  cent,  were 
cured;  (3)  in  70  limbs  excision  of  isolated  varices  cured  74  per  cent.;  (4) 
resection  of  all  or  most  of  either  the  internal  or  the  external  saphenous  (but 
not  both)  cured  46  per  cent,  of  57  limbs;  (5)  Trendelenburg's  (or  variants) 
plus  multiple  resection  and  ligation  cured  60  per  cent,  of  95  limbs;  and  (6) 
complete  saphenectomy  cured  95  per  cent,  of  77  limbs. 

OPERATIONS    TO    PREVENT    EMBOLIC    INFECTION 

It  should  be  well  understood  that  venous  thrombi  are  potentially  far  more 
dangerous  than  those  in  arteries.  The  latter,  if  we  except  the  pulmonary 
artery,  can,  at  worst,  lead  immediately  only  to  the  destruction  of  the  part  sup- 
plied by  its  branches ;  while  venous-  thrombi,  by  fragmentation,  may  cause 
instant  death  through  embolism  of  cerebral  vessels.     Moreover,  they  may,  if 


OPERATIONS    UPON    CAPILLAEIES  327 

infected,  give  rise  to  pyemic  abscesses  from  septic  emboli  in  the  most  distant 
parts  and  tissues,  or  furnish  the  bases  of  an  infective  endocarditis. 

For  these  reasons  considerable  attention  has  lately  been  given  to  the  op- 
erative treatment  of  infective  phlebitis.  Ligation  and  excision  of  the  internal 
jugular  to  prevent  dissemination  of  infection  in  cases  of  sigmoid  sinus  throm- 
bosis is  a  well  established  procedure ;  v^^hile  similar  treatment  of  the  ovarian  and 
uterine  veins,  in  cases  of  pelvic  thrombosis  of  septic  origin,  has  recently  been 
reported  by  Jellett.  Moreover,  jSTeuhof  has  done  some  experimental  v^ork  in 
testing  the  practicability  of  ligation  of  the  portal  vein  w^ith  a  viev7  to  its  applica- 
tion in  the  treatment  of  suppurative  pylephlebitis. 

Whatever  its  situation,  the  principle  in  the  operative  treatment  of  infective 
thrombophlebitis  is  the  same :  to  ligate  the  vein  on  the  cardiac  side  of  the 
diseased  process,  and  evacuate  the  clot,  or  to  ligate  it  both  centrally  and  dis- 
tally  and  excise  the  segment  betw^een.  Binnie  quotes  Trendelenburg  as  record- 
ing a  case  of  "general,  chronic  puerperal  infection  v^^hich  recovered  after  liga- 
tion of  the  inflamed  and  thrombosed  right  internal  iliac  and  spermatic  veins." 

Faix  mentions  20  cases  reported  operated  for  pelvic  thrombosis  from  the 
clinics  of  Freund,  Trendelenburg,  Michel,  Bumm,  Hackel,  Opitz,  and  Fried- 
man, of  which  7  recovered — a  65  per  cent,  mortality.  Bumm  puts  the  mor- 
tality of  non-operated  cases  at  85  per  cent.  Bremm'er  reports  32  cases  operated 
for  mesenteric  thrombosis  with  5  recoveries — 85  per  cent,  mortality. 

III.     OPERATIONS  UPON  CAPILLARIES 

OPERATIONS  TO  CHECK  BLEEDING 

Local  Coagulants. — Local  coagulants  may  sometimes  be  used  with  advan- 
tage to  check  capillary  oozing.  Of  these  the  most  commonly  used  at  present 
are  hot  water,  hydrogen  peroxid,  and  adrenalin.  Gelatin  is  excellent  also,  but 
not  so  simple  to  prepare  and  use. 

ADEENALIN. -^Adrenalin  is  used  as  a  solution  in  the  strength  of  1:1,000 
applied  on  a  gauze  or  cotton  sponge,  or  sprayed  from  an  atomizer.  It  is  par- 
ticularly useful  in  capillary  bleeding  from  the  mucous  membrane  of  ear,  nose, 
and  throat,  or  abraded  skin  surface. 

HYDEOGEN  PEEOXID. — Hydrogen  peroxid  is  useful  in  oozing  of  large 
wound  surfaces  upon  which  it  may  be  poured  or  applied  by  sponges. 

HOT  WATEE. — Ilot  water  should  be  used  at  a  temperature  not  over  140.  It 
may  be  sponged  or  poured  on  the  oozing  surface. 

GELATIN. — Gelatin  in  5  per  cent,  or  10  per  cent,  solution,  dissolved  in 
normal  saline  heated  from  40°  to  60°  C,  is  applied  to  the  bleeding  surface,  or 
packed  into  the  wound  on  a  saturated  gauze  compress.  The  possibility  of 
tetanus  infection  from  this  source  necessitates  the  previous  perfect  steriliza- 
tion of  the  gelatin.  Equal  parts  of  tannin  and  antipyrin  in  a  gauze  sachet  have 
been  recommended  by  Park  as  a  local  hemostatic  in  bleeding  ulcers  of  malig- 


328  OPEEATIO^S    UPO^    BLOOD    VESSELS 

nant  neoplasms.  Matas  advises  gauze  compresses  wrung  out  of  a  5  per  cent, 
solution  of  antipjrin  to  cover  oozing  surfaces  or  pack  cavities,  and  sachets  of 
compound  alum  powder  (Squibb's  surgical  powder)  to  pack  bleeding  cavities. 
Combined  with  any  of  these  local  coagulants,  calcium  chlorid,  1  to  2  grains  in 
a  neutral  solution  of  1 :  20  strength  injected  deeply  into  the  tissues,  and  in  5- 
grain  doses  by  mouth  or  rectum,  will  materially  aid  in  reducing  coagulation 
time  of  blood. 

Gelatin,  in  the  form  of  Carnot's  solution,  is  said  to  have  the  same  effect 
when  injected  intravenously  (100  to  200  c.  c.  daily  at  37°  C),  and  thyroid 
extract,  taken  internally,  has  been  recommended  for  the  same  purpose  by 
Taylor. 

Packing. — Packing  with  sterile  gauze  is  undoubtedly  one  of  the  most  effi- 
cient means  employed  to  check  oozing  from  the  walls  of  a  wound  or  cavity.  It 
should  not  be  too  tight,  and  should  be  soaked  with  peroxid  or  sterile  saline 
before  being  removed  on  the  second  or  third  day.  The  actual  cautery,  heated 
by  burning  benzin,  or  by  electricity,  is  a  most  efficient  agent  in  controlling 
capillary  hemorrhage.  The  object  of  cauterization  is  to  produce  a  burned 
crust  sufficiently  strong  to  withstand  the  pressure  of  the  blood,  and  for  this 
purpose  it  should  be  used  at  a  cherry  red,  not  white,  heat,  in  order  to  cook  the 
tissue  slowly  and  thoroughly,  rather  than  reduce  it  to  an  ash.  This  crust  must 
not  be  disturbed  until  the  vessels  beneath  it  have  filled  up  with  clot,  or  bleed- 
ing will  recommence. 

Ligation  en  Masse. — Ligation  en  masse  may  be  practiced  as  described  in 
ligation  of  arteries  en  masse.  This  for  the  purpose  of  checking  capillary  ooz- 
ing in  parenchyma  of  organs  such  as  liver,  spleen,  and  kidney. 

OPERATIONS    TO    OBLITERATE    THE    VASCULAR    CHANNELS    IN    SMALL 

ANGIOMATA    AND    NEVI 

Excision. — Excision  of  small,  nevi  is  easy,  the  flaps  of  the  wovind  being 
readily  brought  together  with  sutures.  Larger  nevi,  when  excised,  may  leave 
an  area  denuded  that  has  to  be  covered  by  a  plastic  operation,  or  by  skin  graft. 
The  incision  should  pass  only  through  healthy  tissue,  and  hemostasis  must  be 
carefully  attended  to. 

Freezing. — Freezing  is  the  treatment  par  excellence  for  ordinary  nevi. 
The  freezing  may  be  done  by  liquid  air  or  by  carbon  dioxid  snow.  The  latter 
is  easier  to  obtain.  If  liquid  air  is  to  be  used  make  a  firm  pad  of  cotton  on  a 
small  stick.  Dip  the  pad  into  the  liquid  air.  Shake  off  any  loose  drops  of  the 
liquid.  Press  the  charged  pad  with  moderate  firmness  on  the  nevus  for  a  few 
seconds.  Repeat  the  process  in  every  part  of  the  lesion.  Apply  no  dressings. 
All  scabs  must  be  removed  prior  to  the  treatment,  and  if  any  raw  surfaces  are 
present  they  must  be  covered  with  thin  gauze,  otherwise  the  applicator  would 
freeze  to  them. 

If  carbon  dioxid  is  to  be  used,  a  cylinder  of  the  liquid  is  obtained,  a  paper 


OPERATIONS    UPON    CAPILLARIES 


329 


cone  constructed  and  held  in  front  of  the  outlet  while  the  valve  is  slightly 
opened.  The  liquid  condenses  immediately  into  snow,  which  is  deposited  into 
the  cornucopia,  making  a  cone-shaped  mass  of  snow.  It  may  be  whittled  to  a 
sharp  point  and  held  in  a  thick  layer  of  paper  with  the  point  protruding. 


Ocean 


Fig.  83. — Krogius's  Subcutaneous  Ligature  for  Larger  Angiomata. 


/  / 


ANGIOMA 


This  should  be  pressed  firmly  against  the  growth  in  several  places  for  a  few 
seconds  at  a  time.  No  anesthesia  or  dressings  are  necessary.  With  liquid  air 
or  carbon  dioxid  the  treatment  may  have  to  be  repeated  several  times.  Too 
long  application  may  cause  extensive  sloughing. 

Ligation. — Angiomata  of  the  scalp  may  be  surrounded  by  a  chain  of  sub- 
cutaneous ligatures  (using  full-curved  needle  for  advance  and  quarter-curved 
for  return  part  of  stitch),  which  cure  by  cutting  off  the  blood  supply  in  the 
main  vessel  (Fig.  83),  or  a  purse-string 
suture  with  4  loops  may  be  used  to  strangu- 
late the  growth  (Fig.  84). 

Injection. — Injection  of  astringents, 
cauterization,  and  scarification,  methods 
formerly  much  in  use,  are  not  approved 
at  the  present  time.  Acupuncture,  or 
needling  of  the  nevus,  is  a  method  still 
occasionally  used.  It  is  painful  and  gives 
rise  to  a  certain  amount  of  scarring,  but 
it  is  efficient.  The  needle  is  heated  to  red- 
ness by  electricity.  It  should  be  intro- 
duced slowly  and  cautiously  to  avoid  bend- 
ing, and  should  be  removed  slowly  to  avoid 
hemorrhage  on  account  of  the  cooked  tis- 
sue sticking  to  the  needle  and  being  torn 
away  with  it. 

Wyeth  has  treated  arterial,  venous,  and 
capillary  angiomata  with  injections  of  boiling  water,  under  general  anesthesia. 
For  capillary  growths  he  advises  water  at  about  190°  F.,  throwing  in  2  to  6 
minims  at  a  puncture,  and  beginning  at  the  periphery  of  the  growth  and  work- 
ing toward  the  center.  A  surgical  dressing  is  then  applied  and  the  part  kept  at 
rest.    The  injection  may  be  repeated  in  7  to  10  days. 

Desiccation. — ^Desiccation,  the  electric  desiccation  of  vascular  nevi  by  high- 
frequency  currents,  is  said  by  W.  L.  Clark  to  give  very  excellent  results.     He 


Fig. 


84.  —  Purse-string   Ligature 
Small  Angioma  of  Scalp. 


330  OPEEATIOI^S    UPON^    BLOOD    VESSELS 

advises  that  the  destruction  of  the  nevi,  unless  very  large,  should  be  completed 
at  one  sitting.  In  superficial  lesions  new  skin  is  formed.  Deep  lesions  are 
replaced  by  scar  tissue  and  skin.  To  avoid  cupping,  irregularities  of  the  sur- 
face, and  possibly  keloid  formation,  care  must  be  taken  to  destroy  the  tissue 
perfectly  evenly,  and  not  too  deeply.  The  desiccation  action  is  apparently  a 
rapid  dehydration  of  the  tissue,  rupturing  the  cell  capsule  and  converting  the 
treated  area  into  a  dry  mass.  Penetration  of  the  tissue  is  said  to  be  from  a 
small  fraction  of  an  inch  to  1  inch  or  more,  depending  upon  frequency,  dis- 
tance of  electrode  from  body,  time  of  exposure,  and  density  of  tissue.  It  de- 
stroys tissue  without  opening  blood  or  lymph  channels  and  acts  as  a  styptic 
when  there  is  oozing  of  blood.  The  dry  crust  acts  as  a  dressing  and  separates 
in  3  to  7  days  and  skin  regeneration  is  said  to  take  place  beneath  it. 

The  treatment  is  not  very  painful  if  applied  with  the  proper  technic,  but 
local  anesthesia  may  be  needed,  or,  in  rare  cases,  general  anesthesia. 

A.  Schuyler  Clark  recommends  the  Kromayer  light  as  being  excellent  for 
"port  wine  marks." 

Choice  of  Method. — The  choice  of  method  will  undoubtedly  vary  with  the 
individual  operator.  Liquid  air,  carbonic  snow,  desiccation,  etc.,  all  give  ex- 
cellent results  in  the  majority  of  cases,  but  all  three  require  some  experience 
for  their  proper  application.  Excision  is  far  less  used  now  than  it  was  formerly, 
and  should  only  be  employed  in  those  cases  that  prove  refractory  to  the  less  radi- 
cal forms  of  treatment.  ITeedling  is  painful,  and  hot  water  injections  are  too 
risky  to  be  recommended. 

There  is  little  danger  in  operating  upon  these  capillary  growths,  for  hemor- 
rhage from  them  is  usually  moderate  in  amount,  and  easily  checked  by  pres- 
sure. Oozing  may  be  obstinate,  however,  after  excision,  and  hemostasis  must 
be  carefully  attended  to  on  account  of  the  bad  effect  of  loss  of  blood  in  young 
children. 

Results  are  excellent,  cures  being  practically  always  possible,  but  not 
always  possible  without  scarring. 


OPERATIONS    UPON   THE   LYMPHATICS 

HANDLEY'S    OPERATION 

For  the  reestablishment  of  lymph  drainage;  intractable  edema  of  the  ex- 
tremities, due  to  blocking  of  lymphatics,  following  chronic  inflammation; 
presence  of  filaria;  Le  Dantec's  "dermodoccus"  (diplodoccus)  ;  scar  forma- 
tion after  excision  of  lymph-nodes,  etc.  The  operation  consists  in  establishing 
artificial  channels  for  lymph  drainage  from  the  edematous  parts  as  substitutes 
for  the  natural  vessels  which  have  become  obstructed. 

Beside  the  usual  dissecting  instruments,  several  long-eyed  probes  and  sev- 
eral lengths  of  ISTo.  12  tubular,  woven  pilk  are  needed, 


OPEKATIONS    UPO]^    LYMPHATICS 


331 


Upper  Extremity.— (1)  Make  a  1-incli  incision  througli  the  skin  in  the  mid 
line  of  front  of  forearm  immediately  above  wrist  (a,  Pig.  85).  (2)  Introduce 
a  probe  through  it  and  pass  it  upward  and  outward  in  the  subcutaneous  areolar 
tissue  to  the  point  b  (Fig.  85)  near  the  elbow.  In- 
cise the  skin  over  it  there  and  push  the  point  of  probe 
out.  (3)  Take  a  double  line  of  'No.  12  silk  twice  as 
long  as  the  arm;  catch  its  mid  point  with  hemostat 
and  wrap  one-half  up  in  sterile  towel,  threading  free 
end  of  other  half  through  eye  of  probe.  Pull  probe 
and  silk  with  it  out  of  incision  b  (Fig.  85).  A  double 
line  of  silk  now  lies  in  subcutaneous  tunnel  a-b  (Fig. 
85)  made  by  probe.  (4)  Reintroduce  probe  through 
incision  b  and  bring  silk  out  through  incision  d  made 
near  insertion  of  deltoid.  (5)  Pass  a  second  probe 
through  incision  a  upward  and  inward,  and  make  it 

emerge    through    in- 
cision c.    The  half  of 

silk   line   which  was 

wrapped  in  towel  is 

now  unwrapped  and 

threaded  through  the 

eye     of    the     probe. 

Pull  probe  and  silk 

out  through  incision 

c     (Fig.     85).      Ee- 


X 


85. — Handley's  Opera- 
tion FOR  Lymphatic  Drain- 
age: Upper  Extremity,  An- 
terior View. 


move  hemostat  from 
silk  so  that  loop  be-     fig 
comes    buried   under 
skin   at   a.      (6)    In 
same     fashion     pass 

silk  under  skin  from  c  to  d.     Eeintroduce  both 
probes  through  d  and  pass  them,  under  the  skin, 
round  the  shoulder  to  emerge  through  incision  f 
at  posterior  border  of  deltoid  (Fig.  86).     (7) 
In  similar  fashion,  bury  a  double  line  of  silk 
under  skin  of  back  of  arm  along  lines  of  j,  h,  f 
(Fig.  86),  and  j,  k,  f   (Fig.  86).     There  are 
now  8  threads  emerging  through  f.     (8)  Take  a 
long  probe,  cut  ends  of  two  of  emerging  threads 
so  that  they  are  4  inches  shorter  than  it,  and 
thread  them  into  the  eye.     Thrust .  probe,  eye 
first,  through  incision  f  and  make  it  penetrate  under  skin  of  back.     The  probe, 
being  longer  than  silk,  unthreads  itself.     Withdraw  probe  carefully,  leaving 
thread  to  occupy  its  track.    Repeat  the  maneuver  until  all  the  threads  emerging 


Fig.     86. — Handley's     Operation. 
Posterior  View. 


332  opekatio:n^s  iipox  blood  vessels 

at  f  are  buried  in  various  directions  into  subcutaneous  tissues  of  back.      (9) 
Close  all  incisions  with  sutures. 

Handley  states  the  contra-indications  to  the  operation  (after  carcinoma  of 
breast  removal)  to  be : 

(1)  When  general  anesthetic  cannot  be  given. 

(2)  Where  threads  would  have  to  pass  through  cancerous  tissue. 

(3)  When  there  is  growth  present  about  the  shoulder,  and  pain  in  axilla, 
or  lancinating  pain  shooting  down  arm  (i.  e.  nerve  plexus  pain). 

(4)  He  says  that  benefit  is  transient  in  cases  where  secondary  growths,  or 
pleural  effusion,  are  present. 

(5)  It  should  be  reserved  for  severer  cases  of  lymphostasis. 

Lower  Extremity  (Elephantiasis,  Milroy's  Disease,  Congenital  Edema, 
etc.). — The  technic  of  the  operation  is  similar  to  that  in  upper  extremity, 
but  its  accomplishment  is  more  difficult  on  account  of  the  thickened,  irregular 
nature  of  the  skin ;  and  infection  is  more  liable  to  follow  on  account  of  me- 
chanical difficulty  of  getting  a  clear  operating  field. 

The  Face. — Mitchell  did  Handley's  operation  on  a  case  of  solid  edema  of 
eyelid,  following  a  severe  attack  of  erysipelas  that  had  resisted  all  ordinary 
treatment.     The  operation  was  performed  as  follows : 

By  means  of  a  small  curved  incision  in  upper  and  lower  eyelid,  near 
mesial  part,  and  another  lateral  to  outer  canthus,  coarse  strands  of  silk  were 
carried  beneath  the  skin  of  both  eyelids  beyond  the  outer  canthus.  Erom 
there  they  were  led  subcutaneously  downward,  by  means  of  an  incision  lateral 
to  the  angle  of  the  mouth,  and  finally  the  buried  ends  left  beneath  the  skin  of 
the  cheek  near  the  ramus  of  the  lower  jaw. 

Mitchell  performed  a  similar  operation  on  a  patient  with  solid  edema  of 
the  side  of  the  face  and  the  lips,  following  erysipelas,  by  burying  2  silk  threads 
with  their  upper  ends  in  the  masseteric  region  and  their  lower  ends  tucked 
into  the  loose  tissue  behind  the  clavicle.    Results  were  good  in  both  cases. 

Ascites. — Gerrish  says :  "In  a  case  of  atrophic  cirrhosis  with  ascites  Hand- 
ley passed  a  stout  needle,  threaded  with  silk  such  as  he  used  in  lymphangio- 
plasty,  in  and  out  at  a  number  of  points  through  the  peritoneum  and  subjacent 
tissues  of  right  iliac  region,  leaving,  several  series  of  short  loops  projecting 
into  the  cavity.  The  ends  of  these  threads  were  pushed  into  the  areolar  tissue 
of  the  front  of  the  thigh,  passing  near  the  anterior  superior  spine  of  the  ilium, 
and  behind  the  inguinal  ligament.  The  immediate  result  was  not  satisfactory 
and  another  paracentesis  was  needed,  but  ultimately  great  benefit  ensued, 
seeming  to  justify  extensive  trial  of  the  method." 

The  operation  of  lymphangioplasty  is  simple  and  easy,  and  the  dangers 
are  relatively  slight.  Infection  occurred  in  one  of  Handley's  cases  done  for 
lymphedema  of  the  lower  extremity ;  and  in  one  of  Mitchell's  cases  done  for 
edema  of  the  eyelid  one  line  of  silk  had  to  be  removed  on  account  of  the  "irrita- 
tion" it  caused. 

The  results,  however,  were  good  in  almost  every  case,  and  it  is  unques- 


BIBLIOGKAPHY  333 

tionably  the  best  treatment  now  known  for  the  relief  of  the  painful,  intractable 
lymphedema  following  operations  for  carcinoma  of  the  breast. 

BIBLIOGEAPHY 

Aeteeies 

1.  Beeistheim.    Ann.  Surg.,  Feb.,  1912,  Iv,  195. 

2.     .    Jour.  Am.  Med.  Assn.,  1913,  Ix,  ]S^o.  5,  360. 

3.     .    Surgery  of  the  Vascular  System,  1913,  J.  B.  Lippincott,  Phila. 

4.  Bix:s'iE.     Operative  Surgery,  1912,  P.  Blakiston's  Son  and  Co.,  Phila. 

5.  Buchanan.    Surg.,  G}Tiec.  and  Obst.,  Dec,  1912,  648,  xv,  l^o.  6. 

6.  Caeeel.     Surg.,  Gjuec.  and  Obst.,  1912,  xiv,  l^o.  3,  216. 

7.  CoENEN.     Bruns  Beitr.  z.  klin.  Chir.,  1911,  lxx\^,  313. 

8.  DoBEOwoLSKAjA.  Deutsch.  Ztschr.  f.  Chir.,  1912,  cxix;  Abstract  in  Surg., 

Gynec.  and  Obst.,  1913,  xvi,  'No.  2,  55  of  Int.  Abst.  of  Surg. 

9.  Glasstein.    Beitr.  z.  klin.  Chir.,  1911,  Tl,  533. 

10.  Gtjtheie.      Blood   Vessel    Surgery,    1912,   Longmans,   Green   and   Co., 

]sr.  Y. 

11.  Haxsted  and  Vaughan.     Surg.,  Gynec.  and  Obst.,  1912,  xiv,  No.  1,  1. 

12.  Hesse.     Russk.  Vrach.,  1912,  xi,  1789 ;  Abstr.   in  Surg.,  Gynec.  and 

Obst,  1913,  xvi.  No.  3,  179  of  Int.  Abst.  of  Surg. 

13.  HoESLEY.    Ann.  Surg.,  1912,  Feb.,  Iv,  208. 

11.     Jegee.     Die  Technic  der  Gefassnaht,  1913,  August  Hirschwald,  Berlin. 

15.  Key.    Hygeia,  Stockholm,  1913,  xxv,  75.     Abstract  in  Surg.,  Gynec.  and 

Obst.,  1913,  Aug.,  x^di,  183,  of  Int.  Abst.  of  Surg. 

16.  Lejaes.    Bull,  et  mem.  Soc.  de  chir.,  1902,  609. 

17.  Lespinasse  and  Eisenstaedt.     Surg.,  Gjmec.  and  Obst.,  1911,  xii,  ITo. 

5,  477. 

18.  Matas.     Keen's  Surgery,  v,  1909,  W.  B.  Saunders,  Phila. 

19.  MosNY  and  Dumoxt.    Bull,  de  I'Acad.  de  med.,  1911,  Ixvi,  358. 

20.  MuEAD  Bey.    Deutsch.  med.  Wchnschr.,  xxxviii",  1912,  1477. 

21.  O'Day.     J^orthwest  Med.,  1913,  v,  154;  Abstract  in  Surg.,  Gynec.  and 

Obst.,  1913,  xvii,  iN^.  4,  423. 

22.  Oppel.     Arzte  Zeit.,    1913,   xx,   303;   Abstract  in   Surg.,   Gynec.    and 

Obst.,  1913,  Aug.,  xvii,  185,  of  Int.  Abst.  of  Surg. 

23.  Peeimow.     Russk.  Vrach.,  1913,  xii,  127;  Abstract  in  Surg.,  Gynec. 

and  Obst.,  1913,  June,  xvi,  532,  of  Int.  Abst.  of  Surg. 

24.  ScHiLLEE  and  Lobstein.     Deutsch.  Ztschr.  f.  Chir.,  1910,  106,  s.  487. 

25.  Stewaet.     Ann.  Surg.,  1907,  xlvi,  339. 

Capillaeies^  Veins^  and  Lymphatics 

26.  Babcock.    Jour.  Am.  Med.  Assn.,  1910,  Iv,  210. 
2'7.     Bakay.    Orvosi  hetil.,  Budapest,  1911,  Iv,  703. 


334  OPEEATIOKS    UPON    BLOOD    VESSELS 

28.  BooTHBY..   Ann.  Surg.,  1912,  Ivi,  409. 

29.  Brewer.    Jour.  Am.  Med.  Assn.,  1909,  Hi,  412. 

30.  Castle.     Jour.  Am.  Med.  Assn.,  1911,  Ivii,  2128. 

31.  Coenew.    Verhandl.  d.  deutsch.  Gesellsch.  f.  Chir.,  1911,  xl,  246. 

32.  Cole.     South.  Surg,  and  Gynec.  Assn.,  1910,  Abstract  in  Surg.,  Gynec. 

and  Obst.,  Feb.,  1911,  xii,  2,  188. 

33.  Connell^  Karl.     'N.  Y.  City,  personal  communication. 

34.  CooLEY  and  Yaughan.     Jour.  Am.  Med.  Assn.,  1913,  Ix,  435. 

35.  Crile.    Hemorrhage  and  Transfusion,  1909,  D.  Appleton  and  Co.,  K.  Y. 

36.  Crile  and  Dolley.    Jour.  Exper.  Med.,  1906,  8,  713. 

37.  David  and  Curtis.     Surg.,  Gynec.  and  Obst.,  Oct.,  1912,  xv,  4,  476. 

38.  .     Jour.  Am.  Med.  Assn.,  1911,  Ivi,  35. 

39.  .     Jour.  Am.  Med.  Assn.,  1911,  Ivii,  1453. 

40.  Delbet.    Bull,  med.,  Paris,  1906,  xx,  1119. 

41.  DoRRANCE  and  Ginsberg.    Jour.  Am.  Med.  Assn.,  1910,  Iv,  569. 

42.  Doyen.    Zentralbl.  f.  Chir.,  1909,  xxxvi^,  1454. 

43.  Elsberg.     Jour.  Am.  Med.  Assn.,  1909,  lii,  887. 

44.  Enderlen,  v.  Borst.    Mlinchen.  med.  Wchnschr.,  1910,  1865. 

45.  Fauntleeoy.    Med.  Eec,  ^NT.  Y.,  1910,  Ixxviii,  403. 

46.  Foster.     Surg.,  Gynec.  and  Obst.,  Feb.,  1912,  xiv,  2,  202. 

47.  Geinitz.    Mlinchen.  med.  Wchnschr.,  1913,  Ix,  1257. 

48.  Gerrisit.    Keen's  Surgery,  vi,  1913.    W.  B.  Saunders,- Phila. 

49.  GoEcxES.    Med.  Klin.,  1912,  s.  105. 

50.  GoERLici-i.     Beitr.  z.  klin.  Chir.,  1904,  xliv,  278. 

51.  Hahn.    Med.  Eec,  K  Y.,  1910,  Ixxviii,  624. 

52.  Handley.    Brit.  Med.  Jour.,  1910,  I,  825. 

53.  Hepburn.     Ann.  Surg.,  1909,  xlix,  115. 

54.  Hesse  and  Schaack.     Arch.  f.  klin.  Chir.,  1911,  lix. 

55.  .     Ann.  Surg.,  1912,  Iv,  170. 

56.  .    Yerhandl.  d.  deutsch.  Gesellsch.  f.  Chir.,  1911,  xl,  11  Teil,  s.  147. 

57.  Jeannel.     French  Cong,  of  Surg.,  1910. 

58.  Jellett.     Surg.,  Gynec.  and  Obst.,  Aug.,  1913,  xvii,  'No.  2,  147. 

59.  Katzenstein.     Yerhandl.  d.  deutsch.  Gesellsch.  f.  Chir.,  1911,  xl,  I  Teil, 

63. 

60.  Kaysee.    Beitr.  z.  klin.  Chir.,  1910,  Ixviii,  802. 

61.  Keator.    Am.  Jour.  Obst.,  1912,  Ixv,  1003. 

62.  KiMPTON.    Boston  Med.  and  Surg.  Jour.,  1913,  clxix,  ;N"r.  22,  783. 

63.  LiLiENTHAL^  HowAED.     ]^.  Y.  City,  personal  communication. 

64.  LiNDEMAN,  Edwaed.     IST.  Y.  City,  personal  communication. 

65.  .    Eep.  Ped.  Sect.,  IST.  Y.  Acad.  Med.,  Apr.  10,  1913. 

66.  Mamoueian.    Brit.  Med.  Jour.,  1910,  11,  140. 

67.  McClure.     Bull.  Johns  Hopkins  Hosp.,  1909,  xx,  110. 

68.  McGeath.     Surg.,  Gynec.  and  Obst,  March,  1914,  x^dii,  3,  376. 

69.  Millee.    Bull.  Johns  Hopkins  Sosp.,  1906,  xvii,  289. 


BIBLIOGEAPHY  335 

TO.  Mitchell.    Brit.  Med.  Jour.,  1909,  11,  1462. 

71.  MoRiTZ.    Mlinchen.  med.  Wchnschr.,  1911,  Iviii,  395. 

72.  0ml     Deutsch.  Ztsclir.  f.  Chir.,  1912,  118,  s.  172. 

73.  Paye.    Arch.  f.  klin.  Chir.,  Ixxxvii,  803. 

74.  .     Mlinchen;  med.  Wchnschr.,   1912,  lix,   793. 

75.  .     Verhandl.  d.  deutsch.  Gesellsch.  f.  Chir.,  1911,  xl,  11  Teil,  515. 

76.  PecK;,  Chas.  H.    ]^.  Y.  City,  personal  communication. 

77.  Pekthes.    Deutsch.  med.  Wchnschr.,  1895,  xxi,  253. 

78.  Pool  and  McCluee.     Ann.  Surg.,  Oct.,  1910,  lii,  433. 

79.  RiNDFLEiscH  and  Fkiedel.     Arch.  f.  klin.  Chir.,  Ixxxvi,  143. 

80.  RisLEY  and  Ieving.     Boston  Med.  and  Surg.  Jour.,  1912,  clxvi,  956. 

81.  RiTTisK.     Med.  Klin.,  1910,  l^r.  17,  s.  663. 

82.  RosENSTEm.    Verhandl.  d.  deutsch.  Gesellsch.  f.  Chir.,  1912,  2  Teil,  232. 

83.  RuoTTE.     Lyon  med.,  1907,  cxix,  574. 

84.  Satteelee  and  Hookee.    Arch,  of  Int.  Med.,  1914,  xiii,  IsTr.  1,  51. 

85.  TuENUEE,  P.  R.     ]^.  Y.  City,  personal  communication. 

86.  Ungee  and  Bettmann.    Berlin,  klin.  Wchnschr.,  1910,  s.  724. 

87.  Vincent.     Boston  Med.  and  Surg.  Jour.,  1912,  clxvii,  239. 

88.  Hagemann.     Verhandl.  deutsch.  Naturforscher  u.  Aerzte,  1910,  2  Teil, 

s.  121. 

89.  Waltee.     Med.  Klin.,  1911,  ^r.  19,  s.  728. 

90.  Waeeen,  Mortimee.     JST.  Y.  City,  personal  communication. 

91.  Wilson.    Ann.  Surg.,  Dec,  1912,  Ivi,  6,  809. 

92.  WiETiNG.     Deutsch.  zeitschr.  f.  chirurg.,  1911,  ex,  364. 

93.  JSTeuiioff.     Surg.,  Gynec.  and  Obst.,  1913,  xvi,  5,  481. 


A    SPECIAL   METHOD   EOE    THE    TEA^tsfUSIO:NT    OF    BLOQJ 
WITH   THE   IJSE-i3F^BAKAFFI]Sr   AND 


JJSw^ 


COLUMBIA  UNIVERSITY  LIBRARIES  (hslstx) 

Rn  RQS  V27  C.3 


2002303760 


